THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


w 


rtH?0k 


THE 


INTERNATIONAL   ENCYCLOPEDIA 


OF 


SURGERY. 


VOL.  I. 


THE  <£^£6^>/^ 

INTERNATIONAL   ENCYCLOPEDIA  **** 


SUBGEKY 


A   SYSTEMATIC   TREATISE 

ON    THE 

THEORY  AND  PRACTICE  OF  SURGERY 

BY 

AUTHORS   OF  VARIOUS  NATIONS 


EDITED    BY 

JOHN  ASHHURST,  Jr.,  M.D. 

PROFESSOR  OF  CLINICAL  SURGERY  IB  THE  UNIVERSITY  OF  PENNSYLVANIA 


LLUSTRATED   WITH    CHROMO-LITHOGRAPHS   AND   WOOD-CUTS 


IN  SIX  VOLUMES 

YOL.  I. 


NEW    YORK 

WILLIAM    WOOD    &    COMPANY 

18S1 


Copyright  : 
WILLIAM   WOOD    &    COMPANY, 

1881. 


<  OLLIHB,  FBI 


PREFACE. 

v.) 


The  object  of  this  work  is  to  furnish,  in  a  comprehensive  and  yet  not 
unduly  extended  form,  a  Systematic  and  Practical  Treatise  upon  all 
those  subjects  which  are  properly  considered  to  pertain  to  the  Science 
and  Art  of  Surgery,  the  various  topics  discussed  in  the  several  volumes 
having  been  intrusted  to  distinguished  writers  of  various  countries,  who 
are  believed  to  be  specially  qualified  to  give  authoritative  instruction, 
each  upon  the  particular  subject  which  he  has  undertaken. 

The  general  plan  of  the  work  is  as  follows : — 

In  the  First  Volume  are  embraced  such  subjects  as  may  be  looked 
upon  as  belonging  to  General  Surgery,  including  Inflammation, 
regarded  both  from  the  position  of  the  Pathological  Histologist,  and 
from  that  of  the  Clinical  Observer  and  Practical  Surgeon ;  Erysipelas 
and  Pyaemia ;  Hydrophobia  and  Glanders ;  Scrofula  and  Tubercle ; 
Rachitis,  and  Scurvy.  Articles  follow  upon  the  Reciprocal  Effects  of 
Constitutional  Conditions  and  Injuries ;  upon  the  General  Principles 
of  Surgical  Diagnosis ;  upon  Operative  Surgery  in  General ;  upon 
Plastic  and  upon  Minor  Surgery ;  upon  the  use  of  Anaesthetics ;  upon 
Shock;  upon  Traumatic  Delirium  and  Delirium  Tremens;  and  upon 
Amputations. 

In  the  Second  Volume  will  be  begun  the  study  of  Special  Surgery, 
those  affections  being  first  considered  which,  though  local  in  themselves, 
may  yet  be  met  with  in  any  part  of  the  body.  The  Volume  will  also 
contain  articles  upon  the  several  varieties  of  Venereal  Disease,  and 
will  begin  the  discussion  of  Injuries  and  Diseases  of  the  Various 
Tissues  of  the  body. 

(v) 


yj  PREFACE. 

The  Third  and  Fourth  Volumes  will  conclude  the  Surgery  of  the 
Tissues,  and  the  latter  will  also  begin  the  consideration  of  Injuries 
and  Diseases  of  Special  Regions. 

Regional  Surgery  will  be  continued  through  the  Fifth  and  Sixth 
Volumes,  and  the  last  will  contain,  in  addition,  a  History  of  Surgery, 
which  (his  health  permitting)  has  been  promised  by  Professor  Gross. 

An  Appendix  will  embrace  papers  on  Hospital  Construction,  and 
similar  important  topics  of  collateral  interest  to  Surgical  Science ;  and 
a  full  Analytical  Index  will,  in  connection  with  the  Table  of  Con- 
tents and  Subject  Index  in  each  Volume,  serve  to  facilitate  reference 
to  every  part  of  the  work. 

For  the  plan  of  the  Encyclopaedia,  the  arrangement  of  the  material, 
and  the  general  supervision  of  the  whole,  the  Editor  is  responsible,  as 
he  is  also  for  those  Articles  which  bear  his  own  name  (in  the  present 
volume,  the  Article  on  Amputations),  and  for  a  few  notes,  chiefly  in 
regard  to  practical  matters,  which  may  be  distinguished  by  their  being 
included  within  brackets  [thus].  But  for  the  facts  and  opinions  in  the 
various  Articles,  with  the  exceptions  named,  the  entire  responsibility 
rests  with  the  individual  authors.  In  a  work  of  this  character,  some 
repetition  is  unavoidable,  inasmuch  as  the  subjects  of  the  several  Arti- 
cles necessarily  overlap  each  other  in  many  instances;  but  this  very 
circumstance  is  rather  of  advantage  than  otherwise,  as  enabling' the 
render  to  compare  the  independent  views,  upon  questions  of  importance, 
entertained  by  different  writers  of  equal  eminence. 

In  regard  to  the  illustrations  which  accompany  the  work,  it  has  been 
flic  aim  of  both  the  Editor  and  Publishers  to  supply  whatever  might 
he  really  serviceable  in  rendering  the  text  more  clear,  while  at  the  same 
time  introducing  none  which  were  not  truly  illustrative.  For  some 
subjects,  a  large  number  are  required,  while  for  others,  the  use  of  any 
illustrations  would  be  of  at  least  doubtful  value.  In  accordance  with 
tin'  Publishers' preference,  the  plates  and  almost  all  of  the  wood-cuts 
-  |)t.  some  of  instruments,  etc.)  are  original,  and  have  been  executed 


PREFACE.  Vll 

expressly  for  this  work,  either  from  photographs  or  from  drawings, 
many  of  which  are  from  the  skilful  pencil  of  the  Editor's  friend  and 
former  pupil,  Dr.  J.  Madison  Taylor. 

The  Editor  desires  to  offer  his  sincere  thanks  to  the  many  distin- 
guished surgeons  and  physicians,  who — in  several  instances,  at  the  cost 
of  great  personal  inconvenience — have  given  him  their  aid  as  collabora- 
tors, and  without  whose  valued  assistance  the  production  of  the  Ency- 
clopaedia would  have  been  impossible.  His  thanks  are  also  due  for 
important  help  of  various  kinds,  rendered  by  Dr.  W.  M.  Carpenter,  of 
New  York,  and  by  Dr.  H.  R.  Wharton  and  Dr.  F.  C.  Sheppard,  of 
Philadelphia. 

JOHX  ASHHURST,  Jr. 


Philadelphia, 

2000  West  Delancey  Place, 
November,  1881. 


ALPHABETICAL  LIST  OF  AUTHORS. 

(VOL.  I.) 


D.  HAYES  AGNEW, 

JOHN  ASHHURST,  Jr., 

JOHN  H.  BRINTON, 

HENRY  TRENTHAM  BUTLIN, 

FRANCIS  DELAFIELD, 

WILLIAM  S.  FORBES, 

WILLIAM  HUNT, 

CHARLES  T.  HUNTER, 

CHRISTOPHER  JOHNSTON, 

HENRY  M.  LYMAN, 

C.  W.  MANSELL-MOULLIN, 

J.  LEWIS  SMITH, 

ALFRED  STILLE, 

S.  STRICKER, 

WILLIAM  H.  VAN  BUREN, 

A.  VERNEUIL, 

PHILIP  S.  WALES. 


(viii) 


THE  INTERNATIONAL 

ENCYCLOPEDIA  OF  SURGERY. 


ARTICLES  CONTAINED  IN  THE  FIRST  VOLUME. 

Disturbances  of  Nutrition;  the  Pathology  of  Inflammation.  By  S. 
Stricker,  M.D.,  Professor  of  Experimental  and  General  Pathology  in 
the  University  of  Vienna.  Pa^e  1. 

Inflammation.  By  William  H.  Van  Buren,  M.D.,  LL.D.,  Professor  of  the 
Principles  and  Practice  of  Surgery  in  the  Bellevue  Hospital  Medical 
College,  New  York.  Page  65. 

Erysipelas.  By  Alfred  Stille,  M.D.,  LL.D.,  Professor  of  the  Theory  and 
Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of 
Pennsylvania,  Philadelphia.  Pa^e  161. 

Pyemia  and  Allied  Conditions.  By  Francis  Del  afield,  M.D.,  Adjunct 
Professor  of  Pathology  and  Practical  Medicine  in  the  College  of  Physi- 
cians and  Surgeons,  Medical  Department  of  Columbia  College,  New 
York.  Page  203. 

Hydrophobia  and  Rabies.  Glanders.  Malignant  Pustule.  By  W".  S. 
Forbes,  M.D.,  Demonstrator  of  Anatomy  in  the  Jefterson  Medical 
College,  Senior  Surgeon  to  the  Episcopal  Hospital,  Philadelphia. 

Page  215. 

Scrofula  and  Tubercle.  By  Henry  Trentham  Butlin,  F.R.C.S.,  Assistant 
Surgeon  to,  and  Demonstrator  of  Surgery  at,  St.  Bartholomew's  Hospital, 
London.  Page  231. 

Rachitis.  By  J.  Lewis  Smith,  M.D.,  Clinical  Professor  of  Diseases  of  Chil- 
dren in  the  Bellevue  Hospital  Medical  College,  New  York.       Pao-e  251. 

Scurvy.  By  Philip  S.  Wales,  M.D.,  Surgeon-General  of  the  United  States 
^avy-  .  Page  277. 

(ix) 


X  THE   INTERNATIONAL   ENCYCLOPAEDIA   OF   SURGERY. 

The  Eeciprocal  Effects  of  Constitutional  Conditions  and  Injuries.  By 
A.  Verneuil,  M.D.,  Professor  of  Clinical  Surgery  in  the  Faculty  of 
Medicine,  Paris.  Page  307. 

General  Principles  of  Surgical  Diagnosis.  By  D.  Hayes  Agnew,  M.D., 
LL.D.,  Barton  Professor  of  Surgery  in  the  University  of  Pennsylvania, 
Surgeon  to  the  Pennsylvania  Hospital,  Philadelphia.  Page  337. 

Shock.  By  C.  W.  Mansell-Moullin,  M.A.,  M.D.  Oxon.,  F.R.C.S.,  Fellow 
of  Pembroke  College,  Oxford;  Late  Travelling  Fellow,  Univ.  Oxon.; 
Surgical  Registrar  to  the  London  Hospital,  London.  Page  357. 

Traumatic  Delirium  and  Delirium  Tremens.  By  William  Hunt,  M.D., 
Senior  Surgeon  to  the  Pennsylvania  Hospital,  Philadelphia.      Page  379. 

Anjesthetics  and  Anesthesia.  By  Henry  M.  Lyman,  A.M.,  M.D.,  Professor 
of  Physiology  and  of  Diseases  of  the  Nervous  System  in  the  Rush  Medi- 
cal College,  Chicago.  Page  403. 

Operative  Surgery  in  General.  By  John  H.  Brinton,  M.D.,  Lecturer  on 
Operative  Surgery  in  the  Jefferson  Medical  College  and  Surgeon  to  the 
Jefferson  Medical  College  Hospital,  Surgeon  to  the  Philadelphia  Hospi- 
tal, and  to  St.  Joseph's  Hospital,  Philadelphia.  Page  435. 

Minor  Surgery.  By  Charles  T.  Hunter,  M.D.,  Demonstrator  of  Anatomy 
in  the  University  of  Pennsylvania,  Surgeon  to  the  Episcopal  Hospital, 
Philadelphia.  Page  479. 

Plastic  Surgery.  By  Christopher  Johnston,  M.D.,  Emeritus  Professor  of 
Surgery  in  the  University  of  Maryland,  Baltimore.  Page  531. 

Amputations.  By  John  Ashiiurst,  Jr.,  M.D.,  Professor  of  Clinical  Surgery 
in  the  University  of  Pennsylvania,  Philadelphia.  Page  551. 


CONTENTS 


Preface  ..... 
Alphabetical  List  of  Authors  in  Vol.  I. 
List  of  Articles  in  Vol.  I.    . 
List  of  Illustrations 


PAGE 
V 

viii 

ix 

xxxvi 


DISTURBANCES  OF  NUTRITION ;   THE  PATHOLOGY  OF 

INFLAMMATION. 

By 
S.  STRICKER,  M.D., 

professor  of  experimental  and  general  pathology  in  the  UNIVERSITY  OF  VIENNA. 


the  contractility  of  the  cells  of 


(Translated  by  ALFRED  MEYER,  M.D.,  of  New  York.) 

Hyperemia         .  .  '     . 

Active  hyperemia 

Passive  hyperemia 
Anosmia  and  ischemia    . 
Causes  of  hyperemia  and  ischemia 

Contractile  elements  of  bloodvessels 

Contractility  of  the  capillaries 

Contractility  of  the  capillaries  compared  to 
glands      .... 

The  vaso-motor  nerves 
Hyperemia  of  irritation  and  paralysis    . 
The  mechanical  hyperemias 

Consequences  of  hyperemia  ;  oedema  and  hemorrhage 
Cardinal  symptoms  of  inflammation 

General  remarks  concerning  the  inflammatory  changes  of  tissues 
Historical  remarks  concerning  the  theory  of  inflammation 

Virchow's  suppuration-theory 

Cohnheim's  migration-theory 

Doctrine  of  the  tissue-metamorphosis 
Suppurative  keratitis      .... 

Paths  for  nutrition  and  spaces  for  collection  of  oedema 

Apparent  migration  of  cells  in  the  midst  of  tissue  and  vital  processes  in  the 

basis-substance  ........ 

(xi) 


1 
2 
3 
3 
4 
4 
5 

9 
11 
18 
19 
20 
23 
24 
25 
25 
25 
27 
28 
33 

34 


Xll 


CONTEXTS. 


Suppurative  inflammation  in  tendon,  cutis,  bone,  cartilage,  and  other  connective 
substances 

Tendon 

Cutis 

Bone 

Cartilage     . 
Theory  of  fibrillar  and  of  connective  substance  . 
On  the  cell-nucleus         ..... 
Comparison  between  the  supposed  fibrillar  substances  and  the  other  connective 

substances 
The  transversely  striped  muscular  fibres  ;  continuation  of  the  discussion  on  the 

nature  of  the  fibrillae 
The  smooth  muscular  fibres  and  the  central   nervous  system  ;  continuation  of 
the  discussion,  etc.  .... 

Smooth  muscular  fibres 

"White  and  gray  matter  of  the  central  nervous  system 

Suppuration  of  the  spinal  cord 
New  observations  on  the  supposed  fixed  cells.     Conclusion  of  the  discussion  on 

the  nature  of  the  fibrillar 
Epithelium  and  endothelium 

Endothelium  .... 

Epithelium  .... 

Healing  by  first  intention  and  healing  by  granulation 

Transplantation  of  cutis 
Regeneration      ..... 
Non-inflammatory  new  formations 
Degeneration  of  the  tissues 

Fatty  degeneration 

Amyloid  degeneration 

Calcareous  degeneration 

Colloid  defeneration 


37 
37 
38 
38 
38 
41 
42 

43 

44 

47 
47 
47 
48 

51 
55 
55 
56 
57 
58 
59 
60 
61 
61 
62 
62 
62 


INFLAMMATION. 


By 
WILLIAM  II.  VAN  BITREN,  M.D.,  LL.D., 

pi:'. I  ESBSOB  or  THE  PRINCIPLES  A.M.  IUACTICE  OF  SURGERY  IN  THE  BELLEVUE  HOSPITAL 

iMKUICAL  COLLEGE,  NEW  YORK. 


'"  neral  considerations  regarding  inflammation.     Definitions 
of  inflammation 
Irritation  and  injury 
( llassification  of  causes 
Predisposing  can  i 

I  >efect  in  quality  of  blood 
l'i esence  of  poison  in  blood 


65 

68 
68 
68 
70 
70 
71 


CONTENTS. 


Xlll 


Causes  of  inflammation — 

Defective  or  deranged  nervous  supply- 
Period  of  life  . 

Habit  of  body,  etc. 

Habitual  functional  hyperemia 

Climate,  etc.    . 
Exciting  causes 

Cold  and  sudden  chilling 

Incised  wounds 

Punctured  wounds 

Presence  of  foreign  material  in  woun 

Mechanical  violence,  wrenching,  straining,  etc 

Contusion 

Presence  of  a  clot  of  blood 

Persistent  mechanical  action    . 

Action  of  chemical  irritants    . 

Heat    .... 

Poisonous  action  of  minerals  . 

Poisonous  action  of  plants 

Poisonous  secretions  of  animals 

Venom  of  serpents 

Parasites  ... 

Microscopic  fungi 

Putrid  substances 
Modes  in  which  poisons  are  absorbed 
Symptoms  of  inflammation 

Redness       .... 
Heat  .... 

Swelling      .... 
Pain  .... 

Impairment  or  abolition  of  function 
Traumatic  or  inflammatory  fever 
Phenomena  of  traumatic  fever 
Nature  of  fever 
Causes  of  surgical  fever 
Infective  and  non-infective  inflammation  and  fever 
Blood-poisoning,  septicaemia,  and  pyaemia 
,  Inflammatory  exudations 

Passive  and  active  exudation  ;  oedema 
Exudation  of  plastic  lymph 
Croupous  exudation 
Plastic  or  coagulable  lymph 
Union  by  first  intention 
Healing  under  a  scab 
Destructive  inflammation.     Pus  formation 
Suppuration  and  granulation 

Union  by  secondary  adhesion  . 
Physical  qualities  of  pus     . 


71 

72 

73 

73 

73 

74 

74 

75 

7G 

76 

78 

78 

79 

80 

80 

80 

81 

82 

82 

84 

85 

85 

90 

92 

95 

96 

97 

97 

98 

99 

99 

100 

102 

103 

105 

106 

106 

107 

108 

109 

110 

111 

111 

112 

112 

114 

114 


XIV 


CONTENTS. 


Destructive  inflammation — 

Anatomical  characteristics  of  pus   . 

Liquid  portion  of  pus           . 

Sources  of  pug         ...... 

Abscess            ...... 

Formation  of  pus  on  serous  and  mucous  membranes    . 

115 
116 
116 
117 
119 

Phenomena  attending  pus  formation 
Ulceration           ....... 

Gangrene            ....... 

Significance  of  suppuration         . 

Significance  of  odors  from  pus 

119 
120 
121 
122 
122 

Poisonous  qualities  of  pus  .... 
Pus  involves  waste  of  tissue 

123 
124 

Uses  of  pus              ..... 
Varieties  of  pus              ..... 
Substances  mistaken  for  pus       .... 

124 
125 
126 

Injurious  consequences  of  suppuration    . 

Purulent  infiltration  with  connective-tissue  necrosis 

126 
127 

Hectic  fever       ...... 

129 

Chronic  inflammation     ..... 

130 

Induration                ..... 

131 

Hyperplasia  and  hypertrophy 
Catarrhal  inflammation  ...... 

131 
132 

Inflammation  in  the  scrofulous   .... 

133 

Inflammation  in  the  syphilitic     .... 
Terminations  of  inflammation    .... 

134 
135 

Resolution  ...... 

.       136 

Tissue  production    ..... 
Gangrene    ...... 

.       136 
.       137 

Treatment  of  inflammation        .... 

.       138 

Prevention       ..... 

.       138 

Detection  and  removal  of  causes 

.       139 

Insurance  of  favorable  conditions 
Mitigation  and  control  of  manifestations 

.       139 
.       140 

Prevention ...... 

.       140 

Rest  and  immobility             .... 

142 

Position       ...... 

.       144 

Cold 

. 

.       144 

[rrigation 

. 

.       145 

Beal  ;m<l  moisture 

. 

.       146 

Compression 

. 

.       147 

Blood-letting 

. 

.       149 

lurisions 

.       151 

Drainage 

. 

152 

Revulsion  and  counter-irritation 

153 

I  )erivation  hy 
I  >i'  t  and  Dursing 
Diet     . 

ligation  of  main  artery  . 

154 

154 

.       154 

CONTEXTS. 


XV 


Treatment  of  inflammation — 

Stimulus           ........       155 

Nursing            .... 

155 

Medicines  employed  in  treating  inflammation 

155 

Anodynes         .... 

.       156 

Quinine             .... 

156 

Mercury           .... 

156 

Astringents      .... 

157 

Laxatives  and  cathartics 

157 

Depressants     .... 

158 

Antiseptics      ..... 

159 

ERYSIPELAS. 


By 
ALFRED  STILLfi,  M.D.,  LLD., 

PROFESSOR  OF  THE  THEORY  AND  PRACTICE  OF  MEDICINE  AND  OF  CLINICAL  MEDICINE  IN 
THE  UNIVERSITY  OF  PENNSYLVANIA,  PHILADELPHIA. 


Synonyms  and  derivation  of  name 
History  of  erysipelas 
Causes  of  erysipelas 

Sex  and  age    . 
Cold 

Cachectic  conditions 
Sewer  gas,  etc. 
Contagion  . 

Specific  cause  of  erysipelas 
Causes  of  erysipelas  as  illustrated  by  the  history  of  epidemi 
disease     ..... 
Cases  illustrating  unity  of  various  types 
Connection  of  epidemic  erysipelas  with  puerperal  fever 
Morbid  anatomy  of  erysipelas    . 
Symptoms  of  erysipelas 

Wandering  erysipelas  . 
Temperature  in  erysipelas 
Phlegmonous  erysipelas 
CEdematous  erysipelas 
Gangrenous  erysipelas 
Erysipelas  of  face  and  scalp 
Bilious  erysipelas    . 
Metastatic  erysipelas 
Erysipelas  of  new-born  infants 
Erysipelatous  peritonitis 
Diagnosis  of  erysipelas  . 
Prognosis  of  erysipelas  . 


outbreaks  of  the 


161 
161 
162 
162 
163 
163 
164 
105 
167 

168 
170 
173 
176 
177 
178 
179 
182 
183 
183 
184 
186 
186 
186 
187 
188 
188 


Xvi                                                                       CONTENTS 

PAGE 

Prophylaxis  of  erysipelas            ..... 

190 

Treatment  of  erysipelas 

191 

Views  of  the  ancients  . 

191 

Trousseau's  view 

192 

Blood-letting    . 

193 

Cold    .... 

194 

Astringents  and  stimulants 

194 

Nitrate  of  silver,  iodine,  etc.  . 

195 

Surgical  treatment 

195 

Punctures  and  incisions 

196 

Carbolic  acid  . 

197 

Internal  treatment 

197 

Purgatives  and  emetics 

197 

Alcoholic  stimulants,  etc. 

198 

Quinia 

198 

Tincture  of  chloride  of  iron     . 

199 

Treatment  in  infants  and  old  persons 

201 

Treatment  of  erysipelas  of  air-passages 

201 

Treatment  of  epidemic  erysipelas  . 

201 

PYEMIA  AND  ALLIED  CONDITIONS. 


By 
FRANCIS  DELAFIELD,  M.D., 

ADJUNCT  PROFESSOR  OF  PATHOLOGY  AND  PRACTICAL  MEDICINE  IN  THE  COLLEGE 
OF  PHYSICIANS  AND  SURGEONS,  MEDICAL  DEPARTMENT  OF  COLUMBIA 
COLLEGE,  NEW  YORK. 

Nomenclature  of  pyremia  .......       203 

Nature  of  pyaemia  ........       204 

Theory  of  pus  absorption    .  .  .  .  .  .  .204 

Chemical  theory     ........       204 

Germ  theory  .  .  .  .  .  .  .  .       205 

Examination  of  blood  and  tissues        .....       205 

Experiments  on  animals  ......       206 

Symptoms  and  lesions  of  pyasmia  ......       207 

Mechanical  and  infectious  emboli         .  .  .  .  .211 

Treatment  of  pyaemia    .  .  .  .  .  .  .  .211 

Prolonged  suppuration    ........       213 

Spontaneous  pyaemia       .  -  .  .  .  .214 


CONTEXTS. 


XV11 


HYDROPHOBIA  AND  RABIES;  GLANDERS;   MALIGNANT 

PUSTULE. 


By 


WILLIAM  S.  FORBES,  M.D., 


DEMONSTRATOR  OF  ANATOMY  IN  THE  JEFFERSON  MEDICAL  COLLEGE  ;    SENIOR  SURGEON  TO 
THE  EPISCOPAL  HOSPITAL,  PHILADELPHIA. 


Hydrophobia  and  rabies 
Cause  of  hydrophobia 
Rabies  in  the  dog    . 
Incubation  of  hydrophobia 
Symptoms  of  hydrophobia 
Symptoms  of  first  stage 
Symptoms  of  second  stage 
Symptoms  of  third  stage 
Morbid  anatomy  of  hydrophobia 
Diagnosis  of  hydrophobia 
Prognosis  of  hydrophobia 
Treatment  of  hydrophobia 
Preventive  treatment 
Curative  treatment 
Glanders 

Symptoms  of  glanders 

Symptoms  in  the  horse 
Symptoms  in  man 
Diagnosis  of  glanders 
Prognosis  of  glanders 
Treatment  of  glanders 
Malignant  pustule 

Symptoms  of  malignant  pustule 
Pathology  of  malignant  pustule 
Treatment  of  malignant  pustule 


PAGE 

215 
215 
21G 
217 
218 
218 
218 
219 
219 
220 
221 
222 
222 
223 
225 
225 
225 
226 
227 
227 
227 
228 
228 
229 
229 


SCROFULA  AND  TUBERCLE. 

By 

HENRY  TRENTHAM  BUTLIN,  F.R.C.S., 

ASSISTANT  SURGEON  TO,  AND  DEMONSTRATOR  OF  SURGERY  AT,  ST.  BARTHOLOMEW'S 

HOSPITAL,  LONDON. 

Tubercle  .........       231 

Illustrative  cases     .  .  .  .  .  .  .  .231 

Analysis  of  the  above  cases  ......       23-4 

Morbid  anatomy  of  tubercle  ......        234 

VOL.  I. — B 


XVI 11 


CONTENTS. 


Origin  and  natural  history  of  tubercle 
Infection  of  tubercle 
Nature  of  tubercle  . 
Pathology  of  tubercle 
Treatment  of  tubercle 
Scrofula 

Illustrative  cases     . 

Nature  of  scrofula  . 

Morbid  anatomy  of  scrofula 

Diagnosis  of  scrofula 

Tissues  and  organs  affected  by  scrofula 

Relation  of  scrofula  to  tubercle 

Modifications  produced  by  scrofula  in  other 

Gonorrhoea  and  epididymitis 

Syphilis 

Gout  . 
Causes  and  course  of  scrofula 
Prognosis  of  scrofula 
Treatment  of  scrofula 

Constitutional  treatment 

Local  treatment 


diseases 


PAGE 

235 
236 
237 
238 
238 
240 
240 
241 
242 
242 
243 
244 
245 
245 
245 
246 
246 
246 
247 
247 
248 


RACHITIS. 


By 
J.  LEWIS  SMITH,  M.D., 


CLINICAL  PROFESSOR  OF  DISEASES  OF  CHILDREN  IN  THE  BELLEVUE  HOSPITAL  MEDICAL 

COLLEGE,  NEW  YORK. 

Frequency  of  rachitis      .    *          .              .              .              .              .              .              .       251 

Age  at  which  rachitis  occurs 

252 

Foetal  rachitis 

. 

253 

Causes  of  rachitis 

. 

254 

Inheritance 

. 

254 

Food 

. 

254 

Artificial  production  of  rachitis 

. 

255 

I  bitzmann's  observations 

. 

256 

Anatomical  characters  of  rachitis 

257 

Stage  of  proliferation  and  altered  nutrition 

257 

Cartilaginous  changes  . 

257 

Osseous  changes 

, 

258 

Pathology  of  rachitis 

259 

Stage  of  deformity  . 

260 

Changes  in  cranial  bones 

260 

Cranjotabes 

261 

Symptoms  of  craniotabes  . 

262 

Connection  with  1 

aryngismus  stri< 

lulus 

263 

CONTENTS. 


XIX 


Changes  in  vertebra    . 
Changes  in  maxillae 
Changes  in  ribs 

Changes  in  bones  of  upper  extremity 
Changes  in  bones  of  pelvis 
Changes  in  bones  of  lower  extremity 
Effect  of  rachitis  on  dentition  . 
Changes  in  soft  tissues 
Stage  of  reconstruction 

Symptoms  of  rachitis 

Complications  and  sequela?  of  rachitis     . 

Diagnosis  of  rachitis 

Prognosis  of  rachitis 

Treatment  of  rachitis 
Diet 
Medicines  . 


PAGE 

2G4 
264 

265 
266 
267 
267 
268 
269 
270 
270 
271 
272 
273 
274 
274 
275 


SCURVY. 


By 


PHILIP  S.  WALES,  M.D., 

SURGEON-GENERAL  OF  THE  UNITED  STATES  NAVY. 


Synonyms 

277 

History  of  scurvy 

277 

Etiology  of  scurvy 

285 

Geographical  limitation 

285 

Age 

285 

Sex 

286 

Low  temperature     . 

286 

Depressing  emotions 

286 

Foul  air 

287 

Impure  water 

287 

Individual  peculiarities 

287 

Food  supply 

288 

Use  of  salted  meats 

288 

Deficiency  in  quantity  and  quality 

of  food 

289 

Deficiency  in  variety  of  food 

289 

Morbid  anatomy  of  scurvy 

290 

Rigor  mortis 

290 

Skin  and  connective  tissue 

290 

Periosteum 

291 

Joints 

291 

Serous  membranes 

291 

Mouth,  gums,  etc.  . 

291 

Nervous  system 

291 

XX                                                                        CONTEXTS 

PAGE 

Heart          .........       291 

Lungs          .... 

292 

Stomach  and  bowels 

292 

Liver,  spleen,  and  pancreas 

292 

Kidneys 

292 

Pathology  of  scurvy 

293 

Symptoms  of  scurvy 

295 

Scorbutic  cachexia 

295 

Impairment  of  mental  powers 

296 

Pains  in  limbs 

296 

Changes  in  gums     . 

.       296 

Extravasations  of  blood  and  cedems 

L 

297 

Hemorrhages 

.       298 

Serous  effusions 

298 

Cerebral  symptoms 

.       299 

Embolism,  etc. 

.       299 

Urinary  symptoms  . 

299 

Splenic  and  hepatic  symptoms 

300 

Ophthalmic  and  aural  symptoms 

300 

Fever 

.       300 

Diagnosis  of  scurvy 

301 

Prognosis  of  scurvy 

.       301 

Treatment  of  scurvy 

302 

Prophylaxis 

302 

Curative  treatment 

.       304 

THE  RECIPROCAL  EFFECTS  OF  CONSTITUTIONAL 
CONDITIONS  AND  INJURIES. 

By 
A.  VERNEUIL,  M.D., 

PROFESSOR  OF  CLINICAL  SURGERY  IN  THE  FACULTY  OF  MEDICINE,  PARIS. 


Classification  of  constitutional  conditions 

307 

Reciprocal  influence  of  constitutional  conditions  and  injuries 

308 

Period  of  dyscrasia              .... 

309 

Period  of  peripheral  lesions 

. 

309 

Period  of  visceral  lesions    . 

309 

Time  of  operation 

. 

310 

Mode  of  operation 

310 

Choice  of  dressing 

310 

Constitutional  treatment 

311 

Arthritism 

311 

Rheumatism 

311 

Gout 

. 

312 

Herpetism  . 

313 

CONTENTS 

• 

XXI 

PAGE 

Cancer   ....                                                                                       313 

Scrofula 

315 

Tuberculosis 

316 

Scurvy  . 

317 

Leucocythremia 

318 

Haemophilia 

318 

Syphilis 

319 

Malaria  . 

321 

Alcoholism 

322 

Delirium  tremens 

323 

Morphinism 

324 

Saturnism  or  lead-poisoning 

324 

Hepatism  ;  nephrism  ;  cardism  . 

.       325 

Hepatism     .... 

.       326 

Nephrism    .... 

.       327 

Cardism      .... 

.       329 

Aneurism  of  aorta 

329 

Arterial  atheroma 

.       329 

Locomotor  ataxia  and  various  neuroses  . 

.       329 

Hysteria  and  epilepsy 

.       330 

Insanity      .... 

.       330 

Diabetes  mellitus 

.       330 

Alcohol  diabetes 

.       331 

Phosphaturia,  azoturia,  polyuria,  etc. 

.       331 

Pregnancy          .... 

.       332 

Rules  for  operations  during  pregnancy 

.       334 

Infancy  ..... 

.       334 

Old  age 

.       335 

GENERAL  PRINCIPLES  OF  SURGICAL  DIAGNOSIS. 


By 
D.  HAYES  AGNEW,  M.D.,  LL.D., 

BARTON  PROFESSOR  OF  SURGERY  IN  THE  UNIVERSITY  OF  PENNSYLVANIA,  SURGEON 
TO  THE  PENNSYLVANIA  HOSPITAL,  PHILADELPHIA. 


Analytical  and  synthetical  modes  of  investigation 
Difficulties  in  surgical  diagnosis 
General  examination  of  a  patient 

Age 

Sex 

Occupation 

Habits 

Antecedent  history 

Personal  history 

Mental  and  moral  states 


337 
338 
339 
339 
339 
340 
340 
341 
341 
342 


XX11 


CONTENTS. 


Social  condition 

Residence  . 

Duration  of  disease 
Special  examination  ;  personal  investigation 

Posture  or  attitude 

External  expressions  of  parts 

Information  derived  from  touch 

Weight 

Mobility      . 

Temperature 

Color 

Translucency 

Mensuration 

Sound 

Movements 

Smell 
Interrogation  of  internal  organs 

Circulation 

Thermometry 

Respiration 

Nervous  system 

Significance  of  pain 

Mobility      . 

Digestive  apparatus 

Genito-urinary  system 


PAGE 

342 

343 

343 

343 

343 

343 

345 

345 

345 

345 

345 

345 

346 

346 

346 

347 

347 

347 

348 

349 

350 

351 

351 

352 

354 


SHOCK. 


By 


C.  W.  MA^SELL-MOTTLLIN,  M.A.,  M.D.  Oxon.,  F.R.C.S 

FELLOW  OF  PEMBROKE  COLLEGE,  OXFORD;    LATE  RADCLIFFE'S   TRAVELLING  FELLOW, 
UNIV.  OXON.  ;  SURGICAL  REGISTRAR  TO  THE  LONDON  HOSPITAL,  LONDON. 


Causes  of  shock               . 

.       357 

Mental  emotion 

.       358 

Sex  and  age 

.       359 

Pain            .... 

.       359 

Mental  pre-occupation  and  expectation 
Cases  attended  by  shock 
Symptoms  of  shock 

Prostration  with  excitement 

.  359 
.  359 
.  362 
.       363 

Pathology  of  shock 

.       365 

Goltz's  experiments 

.       366 

Tappeiner's  and  Muller's  experiments 
Lewisson's  experiments 

.  367 
.       369 

uosis  of  shock — reaction 

.       369 

CONTENTS 

• 

XXlll 

PAGB 

Treatment  of  shock         .              .              .              .              .              .             .              .371 

Prevention  of  shock 

371 

External  heat 

.       371 

Stimulants  .... 

.       372 

Opium         .... 

372 

Artificial  respiration  and  transfusion 

372 

Venesection 

373 

Ammonia    .... 

373 

Strychnia,  belladonna,  and  digitalis 

373 

Use  of  anaesthetics 

374 

Fatty  embolism               .... 

374 

TRAUMATIC  DELIRIUM  AND  DELIRIUM  TREMENS. 

By 
WILLIAM  HUNT,  M.D., 

SENIOR  SURGEON  TO  THE  PENNSYLVANIA  HOSPITAL,  PHILADELPHIA. 


Traumatic  delirium 

Meaning  of  term  delirium    . 
Connection  of  delirium  with  insanity 
Anatomy  of  delirium 
Causes  of  traumatic  delirium 

Hemorrhage 

Shock  .... 

Embolism  and  thrombosis 

Lesions  of  nerves  of  special  sense 

Bites  of  serpents 

Bites  and  stings  of  insects,  etc. 

Hydrophobia,  tetanus,  and  chorea 

Surgical  operations 

Surgical  or  traumatic  fever 

Compound  and  simple  fractures 

Lacerated  wounds 

Burns  and  scalds 

Erysipelas 

Epilepsy  and  catalepsy 

Hectic  fever     . 

Pyaemia,  phlebitis,  etc. 
Diagnosis  of  traumatic  delirium 
Treatment  of  traumatic  delirium 
Delirium  tremens 

Causes  of  delirium  tremens 
Delirium  tremens  and  mania  a  potu 
Symptoms  of  delirium  tremens 
Diagnosis  of  delirium  tremens 
Treatment  of  delirium  tremens 


379 
379 
379 
380 
381 
381 
382 
382 
383 
384 
385 
385 
385 
385 
387 
387 
389 
391 
392 
392 
393 
393 
394 
394 
395 
397 
397 
399 
401 


XXIV 


CONTENTS. 


ANESTHETICS  AND  ANAESTHESIA. 


By 
HENRY  M.  LYMAN,  A.M.,  M.D., 


PROFESSOR  OF  PHYSIOLOGY  AND  OF  DISEASES  OF  THE  N 

ERVOUS 

SYSTEM 

IN  THE 

RUSH 

MEDICAL  COLLEGE,  CHICAGO. 

PAGE 

Meaning  of  term  anaesthesia        .......       403 

History  of  anaesthesia 

403 

Early  history 

403 

Nitrous  oxide  gas    . 

404 

Ether           .... 

404 

Chloroform 

405 

Phenomena  of  anaesthesia 

406 

Effect  of  inhalation  on  air-passages 

406 

Effect  on  eyes 

406 

Effect  on  general  sensibility 

406 

Effect  on  brain 

407 

Effect  on  power  of  volition 

407 

Effect  on  power  of  muscular  movements 

407 

Effect  on  reflex  action 

408 

Effect  on  respiration 

.       408 

Effect  on  action  of  heart 

408 

Effect  on  temperature 

408 

Effect  on  secretions 

408 

Physiology  of  anaesthesia 

.       409 

Mode  of  administering  anaesthetics 

412 

Accidents  of  anaesthesia 

412 

Syncope      ..... 

412 

Asphyxia    .... 

412 

Toxic  effect  on  nervous  centres 

414 

Influence  of  rate  of  inhalation 

414 

Influence  of  age,  sex,  temperament,  etc. 

414 

Influence  of  cerebral  and  spinal  diseases 

.       414 

Influence  of  intra-thoracic  diseases 

415 

Influence  of  excitement  or  terror     . 

415 

Treatment  of  accidents  of  anaesthesia 

415 

Employment  of  anaesthetics 

416 

Anaesthesia  in  surgery 

416 

Anaesthesia  in  obstetrics 

416 

Anaesthesia  in  dentistry 

417 

Local  anaesthesia 

418 

Other  modes  of  producing  anaesthesia 

419 

Electricity  .... 

419 

Rapid  respiration    . 

419 

Intravenous  injections 

419 

CONTENTS. 

XXV 

PAGE 

Anaesthetic  mixtures            .......       420 

Hypnotism  ...... 

> 

421 

Compression             ..... 

422 

Mortality  consequent  upon  artificial  anaesthesia  . 

422 

Mortality  from  chloroform  .... 

422 

Mortality  from  ether            .... 

423 

Mortality  from  nitrous  oxide 

423 

Post-mortem  appearances  after  death  from  artificial  anaesthesia 

423 

Anaesthetic  substances    ..... 

424 

Hydrocarbons  and  their  derivatives 

424 

Methane           ..... 

424 

Ethane 

.       424 

Tetrane 

424 

Pentane 

.       425 

Octane 

.       425 

Ethylene 

425 

Amylene 

.       425 

Turpentine 

.       425 

Benzene 

425 

Methylic  chloride 

426 

Methylene  bichloride  . 

.       426 

Chloroform 

426 

Carbonic  tetrachloride 

426 

Methylic  iodide 

427 

Iodoform 

427 

Hydrochloric  ether 

427 

Dichlorethane 

427 

Trichlorethane 

.       428 

Aran's  ether    . 

428 

Bromide  of  ethyl 

. 

428 

Hydriodic  ether 

429 

Monochlorotetrane 

429 

Chloride  of  amyl 

429 

Iodide  of  amyl 

429 

Nitrite  of  amyl 

429 

Pyrrol    . 

429 

Alcohols 

430 

Wood  spirit 

430 

Alcohol 

430 

Carbolic  acid  . 

430 

Chloral  hydrate 

430 

Butylchloral  hydrate 

430 

Ethers 

431 

Methylic  ether 

431 

Ether  . 

431 

Methylal 

431 

Ethereal  salts 

431 

Nitric  ether     . 

431 

XXVI 

.    cc 

IM'EMc 

PAGE 

Formic  ether   ........       432 

Acetic  ether     . 

432 

Aldehydes  . 

432 

Ketones 

432 

Inorganic  substances 

432 

Nitrogen 

432 

Nitrous  oxide  . 

432 

Carbonic  oxide 

433 

Carbonic  acid 

433 

Bisulphide  of  carbon 

433 

Supplementary  note  as  to  deaths  from  chloroform 

.       433 

OPERATIVE  SURGERY  IN  GENERAL. 


By 


JOHN  H.  BRINTON,  M.D., 


LECTURER  ON  OPERATIVE  SURGERY  IN  THE  JEFFERSON  MEDICAL  COLLEGE,  AND  SURGEON 
TO  THE  JEFFERSON  MEDICAL  COLLEGE  HOSPITAL,  SURGEON  TO  THE  PHILADELPHIA 
HOSPITAL,  AND  TO  ST.  JOSEPH'S  HOSPITAL,   PHILADELPHIA. 


Qualifications  of  a  surgeon 

Personal  qualifications 

Knowledge  of  anatomy 

Demeanor  .... 

Selection  of  cases,  etc. 

Diagnostic  power     . 
Preparation  for  an  operation 

Operations  of  necessity  and  expediency 

Time  for  operation 

Preparation  of  patient 

Rest  .... 

Preliminary  treatment 
Anaesthesia         .... 

Comparison  of  ether  with  chloroform 

First  insensibility  from  ether 

Administration  of  ether 

After-treatment  of  ether  anaesthesia 

Administration  of  chloroform 

Local  anaesthesia    . 

Otlur  means  of  producing  anaesthesia 
Mode  of  conducting  an  operation 

i-tants  .... 

Posture  of  patient  . 

Immediate  dangers 

Instruments 

1  fee  of  blunt  knives     . 


435 
435 
436 
437 
437 
438 
438 
439 
439 
440 
440 
441 
441 
442 
443 
443 
445 
446 
447 
448 
448 
449 
449 
449 
4,50 
451 


CONTEXTS 

XXVll 

PAGE 

Drainage     .........       451 

After-dressing          .... 

451 

Treatment  of  patients  after  operation     . 

452 

Diet             ..... 

453 

Care  of  bladder  and  bowels 

454 

Hygienic  surroundings 

454 

Traumatic  or  surgical  fever 

455 

Conditions  determining  results  of  operations 

456 

General  condition  of  patient 

457 

Obesity              .... 

457 

Plethora           .... 

458 

Leanness          .... 

458 

Habits  of  patient    .... 

458 

Drunkenness    .... 

458 

Gluttony          .... 

459 

Influence  of  nervous  system 

459 

Age  and  sex 

459 

Age     ..... 

,      459 

Sex      .... 

4G0 

Race  and  temperament 

461 

Seasons  and  weather 

461 

Locality      .... 

463 

Visceral  affections  . 

463 

Heart  and  arteries 

463 

Lungs 

464 

Urinary  organs 

465 

Liver  .... 

467 

Bowel  affections 

467 

Cachexia?    .... 

468 

Conditions  connected  with  operation  itself 

469 

Hemorrhage    . 

469 

Shock 

469 

Local  condition 

.       470 

Hemorrhagic  diathesis 

470 

Condition  of  patient  after  operation 

470 

Hospital  hygiene 

.       471 

Causes  of  death  after  operations 

472 

Hemorrhage 

.       472 

Shock          .... 

.       473 

Delirium      .... 

.       475 

Thrombosis  and  embolism  . 

475 

Air  in  veins 

476 

Gangrene  and  sloughing 

476 

Tetanus       .... 

476 

Erysipelas  .... 

477 

Pyaemia  and  septicaemia 

477 

XXY111 


CONTENTS. 


MINOR  SURGERY. 

By 
CHARLES  T.  HUNTER,  M.D., 

DEMONSTRATOR  OF  ANATOMY  IN   THE   UNIVERSITY  OF  PENNSYLVANIA  ;     SURGEON  TO  THE 
EPISCOPAL  HOSPITAL,  PHILADELPHIA. 


Surgical  dressings 
Lint 
Charpie 
Tow 
Oakum 
Cotton 
Paper-lint  . 
Jute  .   . 

Compresses 
Pledget 
Tent 
Meche 

Pellets  and  bullets  . 
Retractors  . 
Oiled  silk    . 

Gutta  perclia  or  rubber  tissue 
Waxed  paper 
Water-proof  paper 
The  protective 
Mackintosh 
Use  of  bandages 

Roller  bandages 

General  rules  for  bandagin< 

Special  bandages     . 

Circular  bandage 

Oblique  bandage 

Spiral  bandage 

Spiral  reversed  bandage 
Spiral  bandages 
Spiral  reversed  of  upper  extremity 

Spiral  of  finger 

Spiral  of  hand  or  dcmi-gauntlet 

Spiral  reversed  of  lower  extremity 

Spiral  of  chest 

Spiral  of  penis 
Spica  bandages 

Spica  of  thumb 

Spica  of  shoulder 

Spica  of  groin 


PAGE 

479 

479 

479 

479 

480 

480 

480 

480 

480 

481 

481 

481 

481 

481 

482 

482 

482 

482 

482 

483 

483 

483 

484 

485 

485 

485 

485 

485 

486 

486 

486 

486 

487 

488 

488 

488 

489 

489 

489 


CONTEXTS. 


XXIX 


Spica  of  both  groins    . 

Spica  of  foot    . 
Figure-of-eight  bandages     . 

Figure-of-eight  of  elbow 

Anterior  figure-of-eight  of  chest 

Posterior  figure-of-eight  of  chest 

Suspensory  and  compressor  of  breast 

Suspensory  and  compressor  of  both  breasts 

Yelpeau's  bandage 
Bandages  for  the  head 

Figure-of-eight  bandage  of  head  and  jaw 

Crossed  or  oblique  bandage  of  angle  of  jaw 

Recurrent  bandage  of  head 

V-bandage  of  head 
Other  roller  bandages 

Recurrent  bandages  for  stumps 

Single  T-bandage 

Double  T-bandage 

Sling  or  four-tailed  bandage     . 

Many-tailed  bandage  of  Scultetus 
Handkerchief  bandages 
Fixed  dressings  or  hardening  bandages 

Plaster-of-Paris  bandage 

Starch  bandage 

Gum  and  chalk  bandage 

Silicate  of  potassium  bandage 

Paraffin  bandage 

Glue  and  oxide  of  zinc  bandage 
Revulsion  and  counter-irritation 
Rubefacients 
Vesicants    . 
Acupuncture 
Issues 

Moxa  . 
Seton 
Actual  cautery 

Paquelin's  cautery 
Bloodletting 

Scarification 

Puncturation 

Cupping 

Dry-cupping 

Wet  or  bloody-cupping 
Leeching     . 

Artificial  or  mechanical  leech 
Venesection 

Bleeding  from  external  jugular 

Bleeding  from  internal  saphena 


PAGE 

490 

490 

491 

491 

491 

492 

492 

493 

493 

493 

493 

494 

494 

495 

495 

495 

496 

496 

496 

497 

497 

498 

498 

500 

500 

500 

500 

500 

500 

501 

501 

502 

502 

503 

503 

504 

505 

505 

505 

505 

505 

505 

506 

507 

508 

508 

509 

509 


XXX 


CONTENTS. 


Arteriotomy 
Transfusion  of  blood 

Direct  transfusion  . 
Aveling's  method 
Roussel's  method 

Indirect  transfusion 
Hewitt's  method 
Allen's  method 
Other  methods 

Arterial  transfusion 

Auto-transfusion 

Intra- venous  injection  of  milk,  etc 
Artificial  respiration 

Mouth  to  mouth  inflation     . 

Richardson's  bellows 

Howard's  direct  method    '  . 

Sylvester's  method  . 

Marshall  Hall's  ready  method 
Vaccination 

Revaccination 
Hypodermic  injections    . 
Aspiration 
Surgical  uses  of  electricity 

Electrolysis 

Galvano-cautery 

Galvanization  and  faradization 
Massage 

Stroking  or  effleurage 

Kneading  or  petrissage 

Percussion  or  tapotement    . 

Passive  and  active  motion  . 

Muscle-beating 
Use  of  the  thermometer  in  surgery 

Clinical  thermometer 

Surface  thermometer 
Use  of  the  sphygmograph 


PAGE 

509 
509 
510 
510 
511 
511 
511 
512 
513 
513 
513 
513 
514 
514 
515 
515 
515 
516 
516 
517 
518 
519 
521 
522 
523 
525 
525 
525 
525 
526 
526 
526 
527 
527 
528 
529 


PLASTIC  SURGERY. 


By 
CHRISTOPHER  JOHNSTON,  M.D., 

EMERITUS  PROFE880R  <>1    SURGERY  IN  THE  UNIVERSITY  OF  MARYLAND,  BALTIMORE. 


Synon 

History  of  plastic  Burgery 

Lesions  remediable  by  plastic  surgery 


531 
532 
533 


CONTEXTS. 


XXXI 


General  principles  of  plastic  operations 
Classification  of  plastic  operations 
General  rules  for  plastic  operations 
Skin  grafting 

Hamilton's  observation 

Reverdin's  observations 

Poncet's  observations 

Bryant's  observations 

Coste's  observations 

Ollier's  observations 

Pollock's  observations 

Bert's  observations 

Martin's  observations 

Hodgen's  observations 

Donnelly's  observations 


PAGE 

535 
536 
537 
538 
539 
539 
543 
543 
543 
544 
544 
546 
546 
547 
549 


AMPUTATIONS. 


Br 


JOHN  ASHHURST,  Jr.,  M.D., 


PROFESSOR  OF  CLINICAL  SURGERY  IX  THE  UNIVERSITY  OF  PENNSYLVANIA,  PHILADELPHIA 


General  remarks  upon  amputation 
History  of  amputation    . 

Among  the  Greeks  and  Romans 

Among  the  Arabians 

During  the  middle  ages 

Invention  of  the  ligature     . 

Invention  of  the  tourniquet 

History  of  circular  operation 

History  of  flap  operation     . 
Conditions  calling  for  amputation 

Avulsion  of  a  limb 

Compound  fractures  and  luxations 

Lacerated  and  contused  wounds 

Gunshot  injuries 

Lesions  of  arteries 

Effects  of  heat  and  cold 

Mortification 

Dry  gangrene  . 
Hospital  gangrene 

Diseases  of  bones  and  joints 

Morbid  growths 

Tetanus 

Deformities 


551 
552 
552 
553 
553 
554 
555 
556 
558 
559 
559 
560 
560 
561 
562 
5G2 
562 
563 
563 
564 
564 
564 
564 


XXX11 


CONTENTS. 


Instruments  required  for  amputation 
Tourniquet 
Esmarch's  apparatus 
Amputating  knives 
Saws 

Cutting  pliers  or  bone-nippers 
Bone  forceps 

Artery  forceps  and  tenacula 
Ligatures     . 
Retractor     . 
Sutures 
Needles 

Dissecting  forceps    • 
Scissors 
Operative  methods  employed  in  amputatior 
Circular  operation   . 
Modified  circular  operation 
Elliptical  operation 
Oval  operation 

Method  of  Scoutetten 

Method  of  Malgaigne 
Single  flap  operation 
Double  flap  operation 

Ravaton's  method 

Vermale's  method 

Sedillot's  method 

Langenbeck's  method 

Teale's  method 

Lister's  method 
Relative  advantages  of  different  modes  of  amputating 
Simultaneous  or  synchronous  amputations 

Table  of  cases  of  synchronous  amputation 
Dressing  the  stump 

Cold-water  dressing 

Air  dressing 

Pneumatic  occlusion  and  pneumatic  aspiratior 

Perchloride  of  iron  dressing 

Open  method 

Antiseptic  dressing 

Wadding  dressing  . 

Bordeaux  and  earth  dressings 

Simple  dressing 

After-treatment  of  stump 
Structure  and  diseases  of  stumps 
Structure  of  stumps 
1  diseases  of  stumps  . 

Sloughing 

Erysipelas  and  difFuse  cellulitis 


PAGE 

565 
5G5 
569 
570 
571 
573 
573 
574 
575 
577 
577 
578 
578 
579 
579 
579 
582 
583 
584 
584 
584 
584 
585 
585 
585 
586 
587 
587 
588 
589 
590 
592 
593 
593 
594 
595 
596 
597 
597 
598 
598 
599 
600 
601 
601 
G01 
602 
602 


CONTENTS. 


XXX111 


Hospital  gangrene 

.Spasm  of  muscles 

Retraction  of  muscles 

Contraction  of  tendons 

Hemorrhage     . 

Aneurism,  etc. 

Neuromata 

Periostitis,  osteitis,  and  osteomyelitis 

Necrosis 

Caries 

Hypertrophy  of  hone  . 

Adventitious  bursa? 
Prothetic  apparatus  and  adaptation  of  artificial  limb 
Prothetic  apparatus  for  upper  extremity 
Prothetic  apparatus  for  lower  extremity 
Mortality  and  causes  of  death  after  amputations 
Table  of  one  hundred  cases  of  amputation 

Analysis  of  causes  of  death  in  above  cases 
Effect  of  age 

Effect  of  constitutional  condition 
Effect  of  sex 
Effect  of  hygienic  surroundings 

Erysipelas,  pysemia,  etc. 
Effect  of  nature  of  lesion    . 
Effect  of  period  of  amputation 
Effect  of  part  involved 
Special  amputations  of  the  upper  extremity 
Amputations  of  fingers    . 
Through  phalanx     . 
Through  interphalangeal  joint 
Entire  finger 
Two  adjoining  fingers 
All  four  fingers 
Amputations  of  hand 

Thumb  through  metacarpal 
Thumb  with  metacarpal 
Through  one  or  more  metacarpals 
Fifth  metacarpal 
Other  metacarpals  . 
Whole  metacarpus  . 
Amputation  at  the  wrist 
Circular  method 
Elliptical  method    . 
Flap  methods 
Amputation  of  the  forearm 
Circular  method 
Flap  methods 
Mixed  methods 
VOL.  I. — C 


PAGE 

602 
602 

602 
603 
603 
604 

cm 

604 
605 
605 

606 

606 

cor, 

(',07 

608 

610 

612 

(317 

618 

622 

622 

023 

624 

625 

627 

629 

631 

631 

631 

631 

632 

631 

63  i 

63 1 

631 

631 

635 

636 

636 

636 

637 

637 

638 

G38 

639 

639 

639 

610 


XXXIV 


CONTENTS. 


Amputation  at  the  elbow 

Elliptical  method     . 

Circular  method 

Flap  methods 
Amputation  of  the  arm  . 

Circular  method 

Oval  method 

Flap  methods 
Amputation  at  the  shoulder 

Oval  method  (Larrey) 

External  nap  method  (Dupuytren) 

Antero-posterior  flap  method  (Lisfranc) 
Amputation  above  the  shoulder 
Special  amputations  of  the  lower  extremity 
Amputations  of  toes 

Through  phalanges 

At  interphalangeal  joint     . 

At  metatarsophalangeal  joint 

All  toes  simultaneously 
Amputations  of  the  foot 

Fifth  toe  with  metatarsal     . 

Great  toe  with  metatarsal    . 

Two  or  more  metatarsals     . 

Through  continuity  of  metatarsus   . 

Entire  metatarsus    . 
Hey's  amputation 
Lisfranc's  amputation  . 

At  medio-tarsal  joint  (Chopart) 

Sub-astragaloid  amputation 

Hancock's  amputation 

Tripier's  amputation 

Other  amputations  . 
Amputations  at  the  ankle 

Syme'a  amputation 

Roux's  amputation  . 

l'irogoff's  amputation 

Fer<russonrs  modification 
o 

Le  Fort's  modification 
Amputation  of  the  leg    . 

Amputation  in  the  lower  third 
Amputation  in  the  middle  or  upper  third 

External  flap  method  (Sedillot) 

Lee's  method   . 
Amputation  above  point  of  election 
Amputations  at  the  knee  and  knee-joint 
Amputation  at  the  knee-joint 

Elliptical  method 

Posterior  Sap  method  . 


PAGE 

640 

G40 

640 

041 

042 

642 

643 

643 

643 

644 

645 

646 

647 

049 

649 

649 

649 

649 

650 

650 

650 

650 

651 

051 

052 

052 

652 

653 

654 

655 

655 

655 

656 

656 

658 

658 

659 

659 

000 

660 

660 

001 

002 

002 

663 

003 

003 

004 


CONTENTS. 


XXXV 


Anterior  flap  method 

Lateral  flap  method 
Amputation  at  the  knee 

Carden's  amputation 

Gritti's  amputation 

Stokes's  amputation 
Amputation  of  the  thigh 

Amputation  in  lower  third 
Amputation  in  middle  or  upper  thii 
Amputation  through  trochanters 
Amputation  at  the  hip-joint 
Oval  method 

Modified  circular  method     . 
Single  flap  method  . 
Antero-posterior  flap  method 

Liston's  method 

Beclard's  method 

Guthrie's  method 
Lateral  flap  method 

Larrey's  method 

Lisfranc's  method 

Dupuytren's  method     . 
Control  of  hemorrhage  during  hip-joint  amputation 
Table  of  cases  of  hip-joint  amputation 

INDEX      .... 


r-AGE 

664 
664 
665 
665 
665 
666 
667 
667 
668 
669 
669 
670 
671 
671 
672 
672 
672 
672 
671 
674 
674 
671 
671 
678 

703 


LIST  OF  ILLUSTRATIONS. 


CHROMOLITHOGRAPHS,  ETC. 

PLATE 

I.   Idling  showing  pyaemic  (metastatic)  abscesses  in  various  stages 
II.   Section  of  liver  showing  pyaemic  or  metastatic  abscesses     . 
III.  Primary  synchronous  amputation  of  left  leg  and  right  hip-joint 


PAGE 

211 
211 
591 


WOOD-CUTS,  ETC. 


9. 
10. 
11. 
12. 
13. 
14, 
17, 
19, 
21. 
22. 
23, 
25, 
27. 
28. 
29. 
30. 
81. 
32. 
33. 
34. 


Diagram  illustrating  condition  of  hyperemia 
Effect  of  injections  of  nitrate  of  silver  on  capillaries 
Contraction  of  capillaries     .... 
Glandular  vesicle  of  frog      .... 
The  same,  with  lumen  of  acinus  filled  up  under  action  of  stimulus 
Effect  of  nitrate  of  silver  solution  on  cornea 
Fibrillar  fasciculi  and  cells  in  tendon 
Temperature  chart  of  erysipelas 
Skeleton  of  rachitic  infant   .... 
Head  of  rachitic  child  .... 

Rachitic  spinal  curvature  in  adult     . 
Rachitic  deformity  of  head,  ribs,  and  radius 
Deformity  of  chest  from  rachitis 
15,  16.  Rachitic  deformities  of  pelvis 
18.   Rachitic  deformities  of  femur     . 
20.    Rachitic  deformities  of  femur,  tibia,  and  fibula 
Appearance  of  child  suffering  from  caries  of  vertebras 
Mode  of  stooping  in  subject  of  spinal  caries 
2  I.  Clinical  thermometers    .... 
26.   ^Esthesiometers  .... 

Dynamometer  ..... 

Temperature  charl  of  fatal  traumatic  delirium  following  excision  of 
Temperature  chart  of  traumatic  delirium  following  amputation  of 
Temperature  charl  of  fatal  traumatic  delirium  following  burns 
Temperature  chart  of  fatal  traumatic  delirium  following  scalds 
"emperature  charl  of  traumatic  delirium  following  burns 
Temperature  charl  of  fatal  mania-a-potu 

Temperature  charl  of  delirium  tremens  following  fracture  of  femur 
(  xxxvi  ) 


elbow 

ind 


2 

6 

9 

10 

10 

29 

37 

180 

253 

203 

264 

2G5 

2G6 

267 

2  07 
208 
344 

3  i  I 
348 
350 
352 
386 
388 
389 
390 
391 
397 
399 


LIST    OF    ILLUSTRATIONS. 


XXX  VI 1 


FIG. 

35. 

36. 
37. 
38. 
39. 
40. 
41. 
42. 
43. 
44. 
45. 
46. 
47. 
48. 
49. 
50. 
51, 
53. 
54. 
55. 
56. 
57. 
58. 
59. 
60. 
61. 
62. 
63. 
64. 
65. 
66. 
67. 
68. 
69. 
70. 
71. 
72. 
73. 
74. 
75. 
76. 
77. 
78. 
79. 
80. 
81. 
82. 


Temperature   chart   of   delirium    tremens  following  compound   fracture  of 

aeture  of  patell 


leg,  etc. 


Temperature  chart  of  delirium  tremens  following  ft 

Codman  and  Shurtleff's  inhaler  for  nitrous  oxide 

The  same,  adapted  for  inhalation  of  ether    . 

Clover's  inhaler  for  ether  and  nitrous  oxide 

Porte-meche  .... 

Bandage  winder        .... 

Mode  of  rolling  bandage  by  hand     . 

Single-headed  roller 

Double-headed  roller 

Circular,  oblique,  and  spiral  turns  of  bandage 

Mode  of  making  reverses 

Spiral  reversed  bandage  of  upper  extremity 

Spiral  bandage  of  finger 

Spiral  bandage  of  hand,  or  demi-gauntlet     . 

Spiral  reversed  bandage  of  lower  extremity 

52.  American  spiral  of  lower  extremity 

Spiral  bandage  of  penis 

Spica  bandage  of  thumb 

Spica  bandage  of  shoulder   . 

Spica  bandage  of  groin 

Spica  bandage  of  both  groins 

Spica  bandage  of  foot 

Anterior  figure-of-eight  bandage  of  chest 

Posterior  figure-of-eight  bandage  of  chest    . 

Suspensory  and  compressor  bandage  of  breast 

Suspensory  and  compressor  bandage  of  both  breasts 

Velpeau's  bandage  . 

Barton's  bandage  for  jaw 

Crossed  or  oblique  bandage  of  angle  of  jaw 

Recurrent  bandage  of  head 

V-bandage  of  head 

Recurrent  bandage  of  stumps 

Bandage  of  Scultetus 

Apparatus  for  winding  plaster  bandages 

Seutin's  pliers  for  removing  fixed  bandages 

Von  Bruns's  pliers  . 

Saw  for  removing  plaster-oi'-Paris  bandages 

Porte-moxa 

Seton  -needle 

Canting  irons  of  various  shapes 

Paquelin's  thermo-cautery   . 

Cupping  glass  and  portable  air  pump 

Scarificator  for  wet-cupping 

Cupping  glass  with  India-rubber  bulb 

Mechanical  leech 

Aveling's  transfusion  apparatus 


400 
401 
413 
413 
413 
481 
483 
484 
484 
484 
485 
485 
486 
487 
487 
487 
488 
488 
489 
489 
490 
490 
490 
491 
492 
492 
492 
493 
494 

494 

495 
495 
4  9  5 
497 
498 
499 
400 
499 
503 
503 
504 
504 
506 
506 
506 
.-,1)7 
510 


XXXVlll 


LIST    OF   ILLUSTRATIONS. 


FIG. 

83.  Roussel's  apparatus  for  transfusion 

84.  Allen's  transfusion  apparatus,  modified 

85.  Funnel  and  tube  for  intra-venous  injection  of  milk 

86.  Strainer  for  intra-venous  injection  of  milk 

87.  Richardson's  bellows  for  artificial  respiration 

88.  Syringe  for  hypodermic  injections 

89.  Mode  of  giving  hypodermic  injection 

90.  Dieulafoy's  aspirator 

91.  Potain's  aspirator  . 

92.  Constant  galvanic  battery  . 

93.  Byrne's  cautery  battery 

94.  Electrodes  for  galvanic  cautery 

95.  Faradic  battery 

96.  Clinical  thermometer 

97.  Surface  thermometer 

98.  Pond's  sphygmograph 

99.  Amputation  of  foot  with  cutting  forceps 

100.  Amputation  with  chisel  and  mallet 

101.  Morel's  tourniquet 

102.  Morel's  tourniquet  improved 

103.  Application  of  common  tourniquet 

104.  Petit's  tourniquet  . 

105.  Modern  tourniquet 

106.  Field  tourniquet     . 
►  107.  Signoroni's  horse-shoe  tourniquet 

108.  Skey's  tourniquet   . 

109.  Hoey's  clamp 

110.  Gross's  arterial  compressor 

111.  Pancoast's  abdominal  tourniquet 

1 1  2.   Lister's  aortic  compressor  . 
113,  114.   Esmarch's  elastic  bandage  and  tube 

115.  Old  knife  for  circular  amputation 

116,  117.  Modern  amputating  knives 
lis.  Double-edged  catlin 
119,120.   Bistoury  and  scalpel  . 

121.  Knife  for  finger  amputations 

122.  Metacarpal  knife    . 
1  2."i.  Amputating  saw 

12  1.  Bow-saw     . 

125.  Small  saw  with  movable  back 

1  26.  Rust's  saw 

]  27.  Butcher's  saw 

128.  Liston'a  cutting  bone  forceps 

12'.).  Fergusson's  lion-jawed  forceps 

l  30.  Farabeufs  forceps 

131.  Cross-spring  forceps 

132.  Catch  forceps 
138.  Slide  forceps 


PAGE 
511 

512 

513 

514 

515 

518 

519 

520 

521 

522 

523 

524 

525 

527 

528 

530 

554 

555 

556 

556 

557 

557 

566 

566 

566 

567 

567 

567 

568 

568 

569 

570 

571 

571 

571 

571 

571 

572 

572 

572 

572 

573 

573 

573 

574 

574 

571 

574 


LIST    OF    ILLUSTRATIONS. 


XXXIX 


FIG. 

134.  Tenaculum  ..... 

135.  Serre-fines  ..... 
13.6,  137.   Nunneley's  clips  ... 

138.  Reef  or  sailor's  knot  .... 

139.  Surgeon's  knot        ..... 

140.  Granny  knot  ..... 

141.  Various  form  of  needle       .... 

142.  Needle  eyed  near  point      .... 

143.  Dissecting  forceps  .... 

144.  Bandage  scissors     ..... 

145.  Scissors  curved  on  flat        .... 

146.  Amputation  of  arm  by  circular  method 

147.  Amputation  of  thigh  by  modified  circular  method 

148.  Amputation  at  elbow  by  elliptical  method  . 

149.  Amputation  of  fingers  by  oval  method 

150.  Amputation  of  forearm  by  double  flap  method 

151.  Amputation  of  forearm  by  Teale's  method 

152.  Stump  resulting  from  amputation  by  Teale's  method 

153.  Irrigating  apparatus  for  cold  water  dressing 

154.  155.  Artificial  arm  .... 
156,  157,  158.  Artificial  hands 

159.  Box  leg      .  .  .  . 

160,  161,  162.  Artificial  legs     .... 

163.  Artificial  foot  ..... 

164,  165.  Artificial  legs 

166.  Skeleton  of  finger,  showing  relation  of  knuckles  and  joint: 

167.  Amputation  of  finger  by  palmar  flap  method 

168.  Amputation  of  entire  finger  by  double  flap  method 

169.  Amputation  of  two  fingers  by  oval  method 

170.  Result  of  partial  amputation  of  hand 

171.  Amputation  of  right  thumb  by  palmar  flap  method 

172.  Amputation  of  left  thumb  by  palmar  flap  method  . 

173.  Amputation  of  fifth  metacarpal  by  internal  flap  method 

174.  Amputation  at  wrist  by  palmar  flap  method 

175.  Amputation  at  elbow  by  external  flap  method 

176.  Amputation  of  arm  by  oval,  or  Guthrie's  method 

177.  Amputation  at  shoulder  by  oval,  or  Larrey's  method 

178.  Result  of  shoulder-joint  amputation  by  Larrey's  method 
179;   Amputation  at  shoulder  by  external  flap,  or  Dupuytren's  method 

180.  Result  of  shoulder-joint  amputation  by  Dupuytren's  method 

181.  Chain  saw  ...... 

182.  Amputation  of  toe  by  oval  method 

183.  Amputation  of  fifth  toe  and  metatarsal  by  oval  method 

184.  Amputation  of  great  toe  and  metatarsal  by  internal  flap  met  hud 

185.  Amputation  of  entire  metatarsus  by  Lisfranc's  method 

186.  Amputation  at  medio-tarsal  joint  by  Chopart's  method 

187.  Sub-astragaloid  amputation  .... 

188.  Stump  from  sub-astragaloid  amputation 


PAGE 

575 

575 

. j  7  5 

576 

576 

576 

578 

578 

578 

579 

579 

581 

583 

583 

584 

586 

587 

588 

594 

607 

608 

608 

609 

610 

610 

631 

632 

633 

634 

634 

635 

635 

636 

638 

641 

642 

611 

CI.-) 

615 

646 

6  IS 

649 

650 

651 

652 

653 

65  1 

655 


xl 


LIST    OF    ILLUSTRATIONS. 


189.  Amputation  at  ankle  by  Syme's  method     . 

1(J0.  Amputation  by  Pirogoff's  method  . 

191.  Amputation  of  leg  by  external  flap,  or  Sedillot's  method 

192.  Amputation  of  leg  by  Lee's  method 

193.  Amputation  at  knee-joint  by  anterior  flap  method  . 

194.  Amputation  at  knee  by  Carden's  method  . 

195.  Amputation  of  thigh  by  double  flap  method 

196.  Amputation  at  hip-joint  by  Beclard's  method 

197.  Amputation  at  hip-joint  by  Guthrie's  method 

198.  Wound  after  amputation  at  hip-joint  by  Guthrie's  met  hoc 

199.  Result  of  hip-joint  amputation  by  Guthrie's  method 


PAGB 

657 
658 

G61 
662 

664 
665 

668 
672 
673 
673 
674 


THE  INTERNATIONAL 
ENCYCLOPAEDIA  OF  SURGERY. 


DISTURBANCES  OF  NUTRITION;  THE  PATHOLOGY 
OF  INFLAMMATION. 


BY 

S.  STRICKER,  M.D., 

PROFESSOR  OF  EXPERIMENTAL  AND  GENERAL  PATHOLOGY  IN  THE  UNIVERSITY  OF  VIENNA. 


TRANSLATED    BY 

ALFRED  MEYER,  M.D., 

OF  NEW  YORK. 


HyPERxEMIA. 

Tiie  expression  Hyperaemia  signifies  a  repletion  of  the  bloodvessels  with 
blood.  When,  however,  the  entire  circulatory  system  is  overfilled,  we  desig- 
nate this  condition  as  Plethora.  The  term  hyperaemia  has  reference  only  to  a 
certain  territory,  to  a  certain  organ  or  portion  of  an  organ.  Consequently, 
when  we  make  use  of  the  word  "hyperaemia,"  we  must  add  the  region  in 
which  this  overfilling  with  blood  has  its  seat.  We  accordingly  speak  of  a 
hyperaemia  of  the  liver,  of  the  kidney,  or  of  the  brain ;  but  we  do  not  say 
that  a  man  is  suffering  from  hyperaemia. 

As  soon  as  the  bloodvessels  dilate,  their  contents  must  increase.  On  the 
other  hand,  hyperaemia  without  dilatation  of  the  bloodvessels  is  an  impossi- 
bility. Hyperaemia  and  dilatation  of  bloodvessels  are  consequently  conditions 
which  are  intimately  connected.  If  we  inject  a  colored  fluid  into  an  organ, 
we  observe  that  it  assumes  the  color  of  the  injected  mass  only  when  the 
capillaries  become  filled  with  the  same.  If  we  employ  a  substance  which 
does  not  find  its  way  into  the  capillaries  (e.  g.,  cinnabar  suspended  in  wax), 
only  the  arteries  or  veins  become  colored,  according  as  we  have  made  the 
injection  into  the  former  or  into  the  latter.  For  the  arteries  and  veins  of  an 
organ  only  form  single  branches,  whereas  the  capillaries  traverse  the  entire 
organ,  forming  a  network  so  dense  that  we  cannot  see  its  meshes  with  the 
vol.  i.— 1  ( 1  ) 


2  PATHOLOGY    OF   INFLAMMATION. 

naked  eye.  Accordingly,  when  this  capillary  network  is  filled  with  a  colored 
fluid,  the  entire  organ  is  diffusely  colored.  Now,  since  hyperemia  is  charac- 
terized by  a  diffuse  coloration  of  the  entire  hypersemic  region,  we  may  con- 
clude with  certainty  that  in  hyperemia  the  capillaries  are  dilated. 

Active  Hyperemia. — In  the  skin,  and  in  the  mucous  membranes  which 
are  accessible  to  inspection,  active  hyperemia  is  characterized  by  a  diffuse, 
bright-red  (arterial)  coloration.  The  reddened  parts  are  also  warmer  to  the 
touch  than  those  around  them.  We  know  already  what  the  diffuse  coloration 
denotes.  It  is  the  expression  of  the  fulness  of  the  capillaries.  The  color  is 
bright  red,  because  the  capillaries  are  filled  with  bright-red,  arterial  blood. 
But  whence  originates  the  elevation  of  the  temperature? 

When  the  skin  becomes  bloodless,  it  cools  off;  it  assumes  the  temperature 
of  the  surrounding  medium.  The  instant  it  becomes  colored  bright  red,  in 
consequence  of  a  dilatation  of  the  bloodvessels,  it  also  becomes  warmer.  It 
is  therefore  probable  that  the  skin  is  heated  by  the  blood ;  that  the  blood- 
vessels behave  here  like  a  system  of  pipes  in  a  steam-heating  apparatus. 
When  warm  water  circulates  through  these,  the  air  in  the  neighborhood  of 
the  pipes  becomes  heated;  when  the  fluid  which  has  entered  is  removed,  the 
surrounding  air  cools  off.  In  view  of  this  state  of  affairs,  we  are  led  to  sup- 
pose that  the  more  quickly  the  blood  circulates  through  a  portion  of  the  skin, 
the  warmer  the  latter  will  become.  And  manifestly  this  increase  of  heat  can 
proceed  until  the  temperature  of  the  hypersemic  territory  has  reached  that 
of  the  blood.  On  the  other  hand,  we  may  conclude,  from  the  increased 
warmth  at  the  seat  of  fluxion  (or  active  hyperemia) — a  condition  the  exist- 
ence of  which  is  readily  demonstrated — that  the  blood-current  is  accelerated 
in  the  congested  part.  As  we  shall  see  hereafter,  the  fact  of  such  an  accelera- 
tion has  been  actually  shown  by  experiment. 

Our  experience  with  regard  to  the  acceleration  of  the  blood-current  leads 
us  to  still  further  conclusions.     Let  r  and  t  (Fig.  1)  represent  two  rivers. 

These  rivers  are  to  be  connected  by  a  canal  a  b. 
F'g- 1-  Let  us  suppose,  furthermore,  that  the  water  in 

R  has  a  greater  descent  than  in  T,  and  conse- 
quently flows  through  the  canal  in  the  direction 
of  the  arrows  from  r  to  t.  If  now  the  canal 
a  b  be  widened  at  a  place  c — let  us  say  by  in- 
troducing a  reservoir  at  c — at  the  moment  of 
widening,  the  current  will  flow  somewhat  more 
rapidly  from  a  to  c,  and  the  acceleration  will 
continue  until  the  reservoir  c  is  filled.  But  as 
soon  as  this  is  accomplished  the  water  will  not 
flow  more  quickly  than  before,  either  at  a  or 
at  /v,  while  at  the  seat  of  the  widening  c,  it  will 
even  flow  more  slowly  than  at  other  points.  If 
the  current  in  the  narrow  parts  of  the  canal  a  b, 
on  oil  her  side  of  the  reservoir  c,  is  to  be  accele- 
rated,  this  canal  must  be  widened  in  its  entire  extent  from  one  mouth  to  the 
other.  Let  us  now  suppose  that  r  is  a  large  artery,  t  a  large  vein,  a  a  small 
artery  which  goes  into  a  hypersemic  portion  of  the  skin,  cits  capillary  plexus, 
and  h  the  small  vein  which  carries  back  the  blood  of  the  congested  region 
into  the  large  vein.  Now  it  is  easy  to  understand  that  a  dilatation  of  the 
capillaries  alone  is  not  sufficient  to  produce  a  permanent  acceleration  of  the 
blood-current,  and  a  permanent  elevation  of  the  temperature.  For  the  pro- 
duction of  this  result  the  entire  vascular  system  of  this  region  must  be  dilated 
— the  small  artery,  the  capillaries,  and  the  small  vein  up  to  its  entrance  in  the 


ANEMIA    AND    ISCHEMIA.  3 

nearest  large  venous  trunk.     Only  under  these  circumstances  can  the  blood 
now  more  rapidly  through  the  part,  and  cause  an  elevation  of  its  temperature. 

Passive  Hyperemia. — The  condition  of  Passive  Hyperemia  is,  in  the  skin, 
characterized  by  a  diffuse,  venous  coloration,  and  by  a  temperature  which  is 
relatively  low.  The  diffuse  coloration  here,  too,  points  to  a  dilatation  of  the 
capillaries,  but  the  low  temperature  makes  us  presume  that  the  blood-current 
in  the  capillaries  is  retarded.  In  the  same  way,  too,  we  can  explain  the 
venous  color.  When  the  blood  flows  more  quickly  than  usual  through  the 
capillaries,  it  is  not  so  deeply  venous  as  it  ordinarily  is  when  it  reaches  the 
veins,  or,  in  other  words,  it  is  of  a  brighter  red.  When  it  flows  more  slowly 
than  usual,  it  is,  on  the  other  hand,  more  intensely  venous.  It  is  thus  quite 
consonant  with  what  has  been  said  that  an  actively  hyperaemic  skin  should 
be  colored  bright  red,  and  that  a  passively  hyperaemic  skin  should  be,  on  the 
contrary,  of  a  venous  color;  and  it  is  therefore  proper  to  designate  an  active 
hyperemia  as  a  fluxion,  and  a  passive  hyperemia  as  a  stagnation.  If  a 
hyperazmia  of  stagnation  is  to  be  produced,  the  blood  must  meet  with  a 
hindrance  in  its  course.  Furthermore,  if  the  direction  of  the  blood-current 
is  a  normal  one,  this  hindrance  must  be  located  on  the  side  of  the  vein.  For 
an  obstruction  in  the  arteries  would  prevent  the  rilling  of  the  capillaries,  and 
an  obstruction  in  the  capillaries  themselves  would  likewise  diminish  their 
contents;  in  either  case  Isehmmia  and  not  Hypercemia  would  be  the  result. 
The  obstruction  can  produce  an  overfilling  only  when  it  is  located  on  the 
venous  side  of  the  circulation;  for  under  such  circumstances  only  can  the 
capillaries  become  filled  and  overfilled  with  blood  streaming  in  from  the 
arteries.  There  is,  however,  one  exception  to  this  general  rule,  viz.,  in  the 
case  of  the  reflux  from  the  veins.  To  avoid  repetition,  this  exception  will 
be  considered  on  a  subsequent  page  (p.  20). 


Anaemia  and  Ischemia. 

The  word  Ancemia  is  ordinarily  employed  in  contradistinction  to  Plethora. 
Anaemia  accordingly  means  an  abnormal  diminution  in  the  amount  of  the 
blood.  But  this  definition  is  not  to  be  accepted  literally.  We  call  a  person 
anaemic  when  his  face,  his  lips,  his  gums  appear  pale ;  but  the  paleness  is  not 
necessarily  due  to  a  diminution  in  the  total  amount  of  blood.  The  individual 
may  have  the  normal  amount,  or  even  an  abnormally  large  amount,  of  blood, 
and  still  look  pale,  because  of  the  number  of  red  blood-corpuscles  being 
decreased,  and  of  their  being  replaced  by  something  else.  In  leucocythatmia, 
for  example,  we  have  a  marked  decrease  of  red  blood-corpuscles  and  an 
increase  of  white  ones.  The  blood  of  a  person  suffering  from  leucocythaemia 
is  not  in  fact  of  so  deep  a  red  as  normal  blood,  but  not  so  much  because  it  has 
too  many  white  corpuscles  as  because  it  contains  too  few  red  ones.  The  blood 
would  be  just  as  pale  even  if  the  white  globules  were  replaced  by  any  other 
colorless  mass,  such,  for  example,  as  blood  plasma.  The  pale  look  of  a  person 
who  has  the  normal  number  of  red  blood-corpuscles  may,  moreover,  be  due  to 
a  deficiency  in  the  amount  of  their  red  coloring  matter,  each  red  blood- 
corpuscle,  under  such  circumstances,  appearing  less  intensely  colored  than  is 
normally  the  case.1 

In  regard  to  the  condition  itself,  however,  it  is  of  subordinate  importance 
to  know  which  of  the  aforesaid  causes  lies  at  the  bottom  of  the  paleness,  since 
under  any  circumstances  it  depends  mainly  on  the  deficiency  of  red  coloring 

•  Duncan,  Wiener  Sitzungsberiehte,  1867. 


4  PATHOLOGY    OF    INFLAMMATION. 

matter.  It  is  this  coloring  matter  (hcemoglobine)  which  takes  up  the  oxygen 
in  the  lungs,  and  then,  while  its  carriers,  the  red  blood-corpuscles,  pass  through 
the  capillaries,  provides  for  the  interchange  of  oxygen  and  carbonic  acid — 
for  the  internal  respiration.  Now  it  is  in  the  main  immaterial  whether  the 
coloring  matter  is  diminished  because  there  is  a  want  of  blood,  or  because  the 
number  of  red  blood-corpuscles  is  too  small,  or  because  they  are  too  pale.  On 
the  other  hand,  a  diminution  of  the  total  amount  of  blood  cannot  be  diagnos- 
ticated at  the  bedside  at  all,  with  the  means  now  at  our  command.  Even  in  - 
the  case  of  anaemia  after  loss  of  blood,  we  cannot  assert  with  certainty  that  it 
is  really  the  diminution  of  the  total  amount  of  blood  which  produces  the 
features  of  the  disease.  The  researches  of  C.  Lndwig  and  his  pupils  have 
shown  us  that  the  blood  is  very  rapidly  replaced  after  hemorrhages,  probably 
by  the  entrance  of  colorless  lymph  into  the  vascular  system ;  while  I  have 
shown,1  on  the  other  hand,  that  a  frog,  for  whose  blood  a  dilute  solution  of 
salt  has  been  as  thoroughly  as  possible  substituted,  has,  a  few  hours  afterwards, 
a  very  large  number  of  white  blood-corpuscles  circulating  in  the  vessels,  with 
a  small  number  of  red  globules.  Finally,  we  must  fake  into  consideration 
the  fact  that  the  pale  color  of  the  face,  lips,  and  gums,  and,  in  general,  of 
every  organ,  may  also  be  produced  by  a  permanent  contraction  of  the  blood- 
vessels. In  this  instance,  too,  the  word  ancemia  is  used,  but  here  in  contra- 
distinction to  hypercemia.  In  the  case  of  local  poverty  of  blood  the  expression 
ischcemia  is  indeed  used;  but  we  very  commonly  speak  of  anaemia  of  the  liver, 
of  the  kidney,  or  of  the  brain,  entirely  without  regard  to  the  total  amount  of 
blood. 

Causes  of  Hyperemia  and  Ischemia. 

The  immediate  cause  of  hyperemia  as  well  as  of  ischsemia  is  doubtless  to 
be  found,  as  I  have  already  (page  1)  remarked,  in  a  change  of  calibre  of  the 
bloodvessels.  The  question  therefore  turns  upon  a  second  cause,  namely,  that 
of  the  contraction  and  dilatation  of  the  vessels.  I  shall  divide  the  answer  to 
this  question  into  several  parts.  I  shall  first  speak  of  the  well-known  arrange- 
ments in  the  vessels  for  the  production  of  contraction  ;  I  shall  next  devote  a 
separate  section  to  the  contractility  of  the  capillaries;  I  shall  then  treat  of 
the  modus  operandi  of  these  movements  separately;  and,  finally,  the  nerves 
which  govern  the  contractions  will  be  considered. 

The  Contractile  Elements  of  the  Bloodvessels. — The  arteries  have  a 
sheath  <>f  circularly-arranged,  smooth,  muscular  fibres,  by  the  contraction  of 
which  the  lumen  must  be  narrowed.  The  larger  the  artery,  the  more  does 
tin.-;  coat  of  smooth  muscular  fibres  become  mixed  with  elastic  elements,  and 
the  more  is  the  contractility  of  the  entire  tube  impaired.  The  capability  of 
contraction  is  accordingly  much  more  marked  in  the  smaller  arteries  than  in 
the  large  ones,  the  smallest  arteries  having  indeed  the  power  of  contracting 
until  their  lumen  has  disappeared.  When  the  contraction  of  the  circular 
muscles  subsides,  the  arteries  must  widen  again  and  refill,  in  consequence  of 
thf  pressure  which  the  blood  (really  the  heart)  exerts  upon  them.  Thus 
contraction  of  the  circular  muscular  fibres  causes  a  narrowing  of  the  vessels, 
while  relaxation  of  the  circular  muscular  fibres  produces  a  widening  of  the 
same.  If  is  generally  supposed  that  the  elastic  tissue  also  takes  part  in  the 
narrowing  of  arteries,  for  it  is  thought  that  the  elastic  fibres  are  distended  by 
the  impulse  which  the  blood  receives  during  systole,  and  assume  their  former 
dimensions  during  diastole.      It  is,  indeed,  true  that  the  arterial  wall  is 

1  Studien  aus  dein  Instit.  f.  experim.  Path.,  18G9. 


CONTRACTILITY    OF    THE    CAPILLARIES.  5 

distended  in  consequence  of  every  systole ;  but  it  is  not  proved  that  the 
so-called  elastic  substances  of  the  arterial  wall  are  involved  in  this  distension. 
In  general,  we  do  not  know  whether  the  elastic  substances  of  the  organism 
possess  any  elasticity  worth  mentioning.  We  must  not  be  deceived  by  the 
name  "elastic;"  the  iibres  have  been  called  elastic,  because  the  filaments  of  a 
torn  end  curve  inward  like  elastic  springs;  but  Ave  do  not  know  if  these  fibres 
are  distensible  like  caoutchouc ;  I  do  not  even  consider  it  at  all  likely.  The 
researches  of  Spina1  show  that  the  elastic  fibres  are  cells  which  have  become 
old  and  resistant;  cells  (or  processes  of  cells)  which,  in  inflammation,  again 
become  as  soft,  as  mobile,  and  as  capable  of  proliferation,  as  young  cells  of 
the  embryo.  There  is  no  reason  for  considering  the  cells  which  have  become 
resistant  to  be  more  distensible  than  the  other  tissues.  I  regard  it  as  more 
likely  that  the  artery,  as  a  whole,  possesses  a  certain  degree  of  elasticity,  and 
that  it  in  toto  possesses  the  power  to  contract  after  a  certain  distension,  as 
soon  as  the  pressure  or  tension  relaxes. 

The  walls  of  veins  likewise  have  smooth  muscular  fibres,  but  not  circularly 
arranged,  as  in  arteries.  And  yet  the  veins  are  contractile  in  a  marked 
degree.  If  we  irritate  mechanically  the  exposed  jugular  vein  of  a  rabbit,  it 
contracts  until  its  lumen  almost  disappears.  The  contraction  of  veins  is  the 
more  striking  because  they  are  also  very  distensible.  As  soon  as  the  blood- 
current  is  obstructed  in  the  jugular  vein,  the  vessel  swells,  although  the  blood 
flows  in  it  under  a  very  low  pressure.  AVe  know  very  little  about  the 
mechanism  of  this  contraction;  it  is  not  clear  how  muscular  fibres  which 
run  lengthwise  can  produce  a  narrowing  of  the  lumen.  The  bloodvessels, 
however,  have  other  arrangements  besides  the  muscular  fibres,  by  means  of 
which  their  lumen  can  be  contracted.  These  arrangements  are  presented  by 
the  Intima. 

The  intima  of  the  bloodvessels  lines  the  entire  vascular  system.  In  the 
heart,  it  is  represented  by  the  endocardium.  The  endocardium  leads  directly 
to  the  intima  of  the  arteries,  which  is  continued  in  the  capillaries,  and  beyond 
the  capillaries  again  becomes  the  intima  of  the  veins.  In  the  capillaries  the 
intima  lies  in  immediate  contact  with  the  surrounding  tissue,  or  is  only 
accompanied  by  the  rudiment  of  an  adventitia.  In  other  words,  the  wall  of 
the  capillaries  consists  of  nothing,  or  almost  nothing,  but  the  intima.  Now 
the  capillaries  possess  a  certain  degree  of  contractility;  they  can  actively 
contract  and  dilate,  although  they  have  no  muscular  fibres.  In  this  state  of 
affairs  we  might  even  suspect  that  the  veins  wrere  capable  of  contraction  and 
dilatation,  in  consequence  of  the  contractility  of  their  intima.  But  the 
contractility  of  the  capillaries  has  not  the  same  character  as  muscular  con- 
tractility. The  doctrine  of  the  contractilit}'  of  the  capillaries  is  not  at  all 
generally  accepted,  and  only  a  portion  of  those  who  accept  it  have  actually 
observed  the  phenomenon.  Therefore  we  must  not  blindly  admit  this 
doctrine,  and  build  up  theories  upon  it.  We  must  first  familiarize  ourselves 
more  closely  with  it,  and,  as  it  is  a  subject  of  very  great  importance  in 
pathology,  and  especially  in  respect  to  the  theory  of  inflammation,  I  shall 
devote  a  separate  section  to  its  consideration. 

The  Contractility  of  the  Capillaries. — In  the  year  1865, 1  for  the  first 
time  advanced  the  assertion  that  the  walls  of  the  capillaries  were  not.  as  was 
at  that  time  supposed,  mere  lifeless,  structureless,2  elastic  membranes,  but 
that  they  consisted  of  a  contractile  substance.  I  had  observed  that  the 
capillaries   of  the   fresh lj'-prepared   membrana  nict'dans  of  the  frog,  when 

1  Mediz.  Jahrbfieher,  1873  und  1875. 

2  Nuclei  had  indeed  been  ascribed  to  thern,  but  with  this  single  exception  they  were  considered 
structureless. 


6  PATHOLOGY    OF    INFLAMMATION. 

examined  in  the  aqueous  humor,  changed  their  lumens;  that  in  certain  places 
the}'  alternately  narrowed  and  widened.  These  observations,  however,  were 
merely  accidental  In  some  of  these  membranes  I  saw  the  change ;  in  many 
others  I  did  not  succeed  in  observing  it.  But,  as  it  was  already  known  at 
that  time  that  the  cells  of  embryos  were  distinguished  by  their  contractility, 
I  chose  the  tadpole  for  a  further  examination  of  the  subject.  For  the  tadpole 
is  the  embryo  of  the  frog,  and  has  this  advantage,  that  the  bloodvessels  can 
be  examined  in  its  transparent  tail  in  vivo — that  is,  as  long  as  the  circulation 
continues ;  and  I  found,  indeed,  that  the  capillaries  of  the  tail1  contracted 
under  the  influence  of  powerful  irritation,  as,  for  example,  under  the  influence 
of  strong  induction  currents.  But  I  was  not  sure  of  the  matter;  at  times  I 
obtained  a  favorable  result,  at  others  not.  I  could,  therefore,  give  no  positive 
answer  regarding  this  property  of  the  capillaries.  A  number  of  additional 
circumstances,  however,  gave  me  an  insight  into  certain  other  properties.  I 
discovered  on  this  occasion  that  the  walls  of  the  vessel  were  pierced  by  red 
blood-corpuscles2 — a  discovery  on  which  Cohnheim  subsequently  based  a  new 
theory  of  suppuration  (migration  theory).  I  found,  furthermore,  that  the 
walls  of  capillaries  were  not  structureless;  that  here  and  there  they  were 
granulated,  like  protoplasm;  that  their  outlines  were  irregular;  that  here 
and  there  the}'  had  points  and  nodules.  Then  I  noticed  that  the  walls  of  the 
capillaries  had  processes  ;3  that  various  phases  of  growth  of  these  processes 
were  recognizable  up  to  a  junction  with  the  processes  of  neighboring  capilla- 
ries. It  appeared  that  these  processes  became  hollowed  out,  commencing  at 
the  root  (at  the  inner  wall  of  the  older  capillary),  and  were  thus  transformed 
into  new  capillaries. 

Walls  of  vessels,  I  argued,  which  resemble  protoplasm,  which  send  out 
processes,  are  living  walls.  The  capillaries  are  protoplasm  in  the  shape  of 
tubes.  Just  as  protoplasm  is  permeable  for  foreign  bodies,  so,  too,  are  the 
walls  of  capillaries.  My  statement  concerning  the  penetration  of  the  vascular 
wall  was  soon  generally  accepted,  but  its  contractility,  and  even  its  permea- 
bility (my  view  of  it),  were  contested.  The  blood-corpuscles,  it  was  said  (in 
<  >i ']  m  >sition  to  my  assertions),  passed  through  openings  (stomata)  of  the  vascular 
walls. 

At  the  same  time,  Eberth,  Aeby,  and  Auerbach,  discovered  (but  each  one 
independently  of  the  other)  that  by  the  injection  of  a  solution  of  nitrate  of 
silver4  into  the  vascular  system,  a  series  of  brown  lines 
Flg-  2'  (Fig.  2)  could  be  produced  in  the  capillaries,  and  in  the 

intima  of  arteries  and  veins;  lines  similar  to  those  ob- 
tained on  the  surface  of  serous  membrane  by  staining 
with  silver.  The  lines  on  the  serous  membranes  are 
regarded  as  the  outlines  of  cells,  and  it  was  accordingly 
said  that  the  brown  lines  of  the  capillaries  were  also 
outlines  of  cells ;  and  the  more  so,  because  nuclei  were 
recognizable  in  the  fields  that  were  bounded  by  the  lines. 
(See  Fig.  2.)  Well,  then,  the  capillaries  were  composed 
of  flat  cells — cells  of  the  same  kind  as  those  which  cover 
the  serous  membranes.  They  were  the  continuation  of  the 
intima  (endothelium)  of  the  arteries;  the  capillaries  them- 
selves were  endothelial  tubes.     At  the  borders  of  the  cells 

1  All  bloodvessels,  whether  large  or  small,  whether  afferent  or  efferent,  are  here  capillaries  as 
regards  Btructure.  They  all  consi.it  merely  of  an  intima.  There  is  not  yet  a  muscular  coat  or  an 
ad  ventitia  present. 

■   Studies  fiber  Bau  and  Lebeu  der  capill.  Blutgcfiisse.     Wiener  Sit/.nngsberiehte,  1866. 

''  'lie-  mere  fact  thai  tl apillaries  had  processes  was  known  previously. 

*  The  method  Ltself  bad  already  bees  made  known  hy  Recklinghausen. 


CONTRACTILITY   OF   THE    CAPILLARIES.  7 

there  were  stomata  through  which  the  blood-corpuscles  passed.  Remak,  and 
subsequently  His,  had  already  asserted  that  the  bloodvessels  were  formed  by 
a  juxtaposition  of  cells,  and  now  it  was  said  this  assertion  was  proved.  The 
brown  lines,  it  was  said,  showed  us  the  places  of  junction  of  the  cells  which 
formed  the  vessel. 

It  seems  to  me,  however,  that  the  supposition  of  the  existence  of  stomata 
in  the  wall  of  the  vessel  is  now  generally  abandoned.  There  is  no  longer  any 
doubt  that  the  blood-globule  can  pass  through  any  point  of  a  capillary.  The 
supposition,  too,  that  the  bloodvessels  are  built  up  by  the  synthesis  of  cells 
(like  a  chimney)  is,  as  far  as  I  know,  no  longer  supported  by  anybody. 
However,  I  must  attribute  great  value  to  the  discovery  of  the  silver-lines. 
For  this  discovery  has  led  me  to  a  theory  which  I  must  now  regard  as  fully 
proved;  to  a  theory  which  is  alike  of  importance  for  the  doctrine  of  inflam- 
mation and  for  that  of  histogenesis.  Since  I  was  compelled  to  accept  the 
existence  of  these  brown  lines,  and  yet,  on  the  other  hand,  was  convinced  of 
the  formation  of  capillaries  by  the  hollowing  out  of  a  formerly  solid  material, 
I  indulged  in  the  following  reflection:  The  capillaries  really  are  formed  by 
the  hollowing  out  of  masses  of  protoplasm.  Subsequently,  the  outlines  of 
single  territories  in  the  walls  are  differentiated  (metamorphosed),  and  these 
territories  appear  to  us  like  cells,  on  account  of  their  nuclei.  Originally,  this 
interpretation  was  based  on  speculation  onl}T,  but  now,  after  I  have  worked 
in  this  direction  for  nearly  fifteen  years,  after  I  have  examined  tissues  of  all 
types  with  regard  to  their  normal  and  pathological  genesis,  this  interpretation 
has  become  a  fundamental  theory. 

This  theory  is  as  follows:  When  the  egg  undergoes  segmentation,  it  is  not 
divided  into  parts  which  fall  asunder.1  This  falling  apart  of  the  subdivisions 
occurs  at  certain  places  only.  The  blood-corpuscles  and  the  lymph-corpuscles 
separate  completely  after  their  division.  On  the  other  hand,  cells  which  form 
a  tissue  remain  connected  at  least  in  groups.  The  partition  here  is  only 
apparent.  A  cell  grows  and  then  transforms  a  portion  of  its  body  (Zell-leib)2 
into  a  dividing  line  between  two  halves.  If  this  process  is  repeated,  a  large 
number  of  cells,  connected  by  such  boundary  lines,  must  finally  be  produced. 
If  the  cells  grow  without  the  development  of  boundary  lines,  we  have  very  large 
cells  produced,  the  so-called  "giant-cells."  These  boundary  lines  are  living 
matter,  just  as  the  cells  themselves,  though  still  differing  from  them  in  some 
respects ;  they  have  been  formed  by  a  chemical  alteration  of  a  portion  of  the 
body  of  the  cell.  The  staining  with  silver  assists  us  in  recognizing  their 
chemical  differentiation;  they  are  more  deeply  stained  than  the  cells.  In 
other  words,  they  absorb  more  silver,  and  therefore  assiime  a  deeper  brown 
color  under  the  influence  of  light.  Such  boundary  lines  occur  between 
endothelium  and  epithelium;  they  occur  between  the  cells  of  the  cornea,  of 
cartilage,  of  bone,  of  tendons,  and  of  other  tissues.  Between  the  endothelium 
and  epithelium,  however,  they  remain  relatively  small  borders  for  life,  whether 
the  cells  grow  or  not.  In  the  cornea,  in  cartilage,  in  bone,  in  tendon  and  in 
other  tissues,  the  intermediate  substances  (Zwischen«ubstanzen)  increase  in 
extent  with  advancing  age,  and  this  increase  takes  place  at  the  expense  of 
the  cells.  The  cells  diminish  in  circumference,  or  entire  cells  perish  ;  that  is 
to  say,  they  are  entirely  converted  into  basis  substance.  I  repeat  it  once  more, 
they  are  transformed,  but  they  remain  alive;  they  can  be  metamorphosed 
again  into  the  form  of  cells,  and  this  is,  in  fact,  what  occurs  when  the  tissues 

1  There  are  some  exceptions  to  this  rule.  The  first  vitelline  spheres  of  the  rahhit's  egg,  for 
example,  look  as  though  they  would  fall  apart  if  the  vitelline  membrane  were  not  there.  But 
that  does  not  hold  for  the  subsequent  segmentation  which  concerns  us  most  here. 

2  A.  Brticke  has  introduced  the  term  "Zell-leib"  into  literature,  and  it  has  been  generally 
accepted.     [Note  of  the  Translator.] 


8  PATHOLOGY    OF    INFLAMMATION. 

suppurate.  This  basis-substance  assumes  a  fixed  character  which  varies 
according  to  the  nature  of  the  tissue;  it  becomes  different  in  bone',  different 
in  tendon,  and  different  in  cartilage.  And  these  peculiarities  of  the  basis- 
substance  invest  the  tissue  with  its  peculiar  type. 

The  metamorphoses  of  tissue  sketched  here  will  be  spoken  of  again  further 
on.  For  the  present  this  reference  will  suffice  to  make  clear  the  structure  of* 
the  capillaries.  We  know  now  that  the  presence  of  the  brown  lines  after 
staining  with  silver  by  no  means  allows  us  to  conclude  that  the  nucleated 
fields  were  once  isolated  and  have  here  been  connected.  And  we  have  no 
cause  for  ignoring  the  experience  that  in  the  tail  of  the  tadpole  the  vessels 
develop  from  solid  sprouts.  A  very  excellent  confirmation  of  this  doctrine  of 
the  development  of  vessels  is  found  in  the  researches  of  E.  Klein1  on  the 
embryo  chick.  The  first  bloodvessels  in  the  embryo  can  evidently  not  be 
produced  as  sprouts  of  already  existing  vessels.  The  first  bloodvessels,  as 
shown  by  Klein,  are  formed  by  single  cells.  The  cells  grow ;  the  peripheral 
part  of  the  enlarged  body  of  the  cell  becomes  bloodvessel ;  the  central  part 
becomes  isolated  from  the  peripheral  by  the  formation  of  slits  between  them, 
so  that  the  central  part  then  lies  in  a  cavity.  By  the  subdivision  of  this 
central  portion  blood-corpuscles  are  formed.*2  We,  accordingly,  have  to  deal 
with  an  encapsulated  closed  bloodvessel,  with  blood-corpuscles  in  the  interior. 
The  individual  capsules  send  out  solid  processes ;  the  processes  become 
hollowed  out,  they  coalesce  with  the  processes  of  other  capsules,  and  thus 
there  is  formed  a  system  of  communicating  canals.  In  principle,  then,  this 
development  of  a  vessel  is  analogous  to  the  one  already  delineated.  In  the 
one  case,  as  in  the  other,  there  are  masses  which  are  at  first  solid,  and 
subsequently  become  hollowed  out.  A  similar  mode  of  formation  of  blood- 
vessels also  occurs  in  neoplasms,  and  Kokitansky  was  the  first  who  described 
them  as  cystic  formations — as  cysts  containing  blood-corpuscles. 

After  all  that  I  have  already  said,  there  can  no  longer  be  any  doubt  that 
in  their  embryonic  state  the  capillaries  consist  of  contractile  protoplasm. 
But  why  do  they  not  react  invariably  in  the  tail  of  the  tadpole  ?3  A  living 
muscle  invariably  contracts  under  the  influence  of  sufficiently  powerful  irrita- 
tion, why  not  the  capillaries?  As  the  result  of  a  comparison  of"  the  capillaries 
of  a  mammalian  embryo  with  those  of  the  tail  of  a  tadpole,  I  have  been  led 
to  suspect  that  the  capillaries  of  the  latter  animal  acquire,  at  an  earlier  period 
than  those  of  the  former,  that  rigidity  which  is  peculiar,  even  in  a  more 
marked  degree,  to  the  vessels  of  the  adult  animal.  The  tadpole,  though  it  is 
an  embryo  as  regards  its  stage  of  development,  still  lives  independently  in 
the  water,  and  uses  its  tail  as  a  means  of  propulsion,  even  before  the  blood 
circulates  in  it.  And  it  is  therefore  readily  understood  why  the  tissue  here 
acquires,  at  an  early  period,  the  rigidity  which  corresponds  to  its  developed 
function.  Accordingly,  in  my  experiments,  I  made  use  of  the  youngest 
tadpoles  possible  (1.5  centimetre  long),  and  directed  my  attention  principally 
to  the  vessels  lying  nearest  the  edge,  because  I  believed  that  their  growth 
began  at  the  margin  of  the  tail.  And,  true  enough,  I  learned4  that  under 
these  circumstances  the  capillaries  regularly  narrowed  their  lumens  after 
every  somewhat  powerful  irritation,  and  again  dilated  the  same  after  the 
removal  of  the  stimulus. 

But,  when  I  lay  stress  upon  the  fact  that  the  capillaries  react  promptly  only 
in  an  early  embryonic  state,  I  do  not  mean  to  say  that  the  capillaries  of  older 
animals  do  not  contract  at  all.     If  we  consider  certain  phenomena  in  living 

'  Wiener  Sitzungsberichte,  Bd.  63. 

2  This  description  is  schematic.  The  occurrences  in  the  interior  of  such  a  cell  are  exceedingly 
variable.     Whal  I  have  described,  however,  is  in  principle  l>,-isr<l  on  observation. 

3  Sic  page  6.  i  Wiener  mediz,  Jahrhucher,  1877. 


CONTRACTILITY    OF    THE    CAPILLARIES.  9 

animals  and  in  living  man — for  instance,  how  quickly  the  face  of  a  man  can 
become  as  pale  as  death — we  are  very  easily  led  to  suppose  that  the  capillaries 
of  the  adult  can  contract  until  their  lumen  has  almost  disappeared ;  for  it  is 
difficult  to  imagine  that  an  organ  can  look  perfectly  bloodless  unless  the 
capillaries  have  been  completely  emptied.  If  my  experiments  with  older 
animals  were  not  always  successful,  this  may  have  been  due  to  the  arrangement 
of  the  experiments  themselves.  Originally  I  made  all  my  observations  on 
curarized  tadpoles,1  because  experiments  where  stimuli  are  employed  cannot 
be  made  under  the  microscope  with  living  animals  unless  they  are  paralyzed; 
the  stimulus  applied  to  the  vessel  also  makes  the  entire  animal  twitch,  and 
the  vessel  under  observation  is  removed  from  the  field  of  view.  Curare 
paralyzes  the  nerves  of  the  voluntary  muscles,  and  the  animal  lies  perfectly 
motionless  if  the  stimuli  are  not  excessively  powerful.  But  we  now  know 
that  curare  also  weakens  the  vaso-motor  nerves.  The  vessels  of  curarized 
animals  do  not  react  to  stimuli  as  do  those  of  the  unpoisoned  animal.  As 
important,  then,  as  these  experiments  may  have  been  for  the  discovery  of 
contractility  in  general,  they  are  not  altogether  reliable  for  a  complete  and 
lucid  representation  of  the  subject.  We  must  therefore  remain  satisfied,  for 
the  present,  to  accept  the  following  as  the  doctrine  of  contractility  of  the 
capillaries:  The  capillaries,  it  has  been  demonstrated,  possess  in  an  embryonic 
state  the  property  of  responding  to  certain  stimuli  by  a  contraction  of  their 
lumen.  With  inereasing  age,  however,  they  become  more  resistant;  their 
irritability  diminishes.  We  do  not  know  if  the  irritability  ever  disappears 
entirely  in  the  course  of  life. 

The  Contractility  of  the  Capillaries  compared  to  the  Contractility 
of  the  Cells  of  Glands.— If  we  reflect,  now,  what  contractions  a  tube  must 
undergo  in  order  to  narrow  its  lumen,  it  appears  that  in  form  also  the  con- 
tractility of  the  capillaries  cannot  be  compared  with  that  of  the  muscles. 
When  a  muscle  contracts  it  becomes  shorter  and  thicker;  but  a  capillary 
cannot  diminish  its  length.  How,  then,  is  the  narrow- 
ing of  the  tube  brought  about?  Golubew2  (a  pupil  of  Fio-  3- 
Rollett)  has  found  that  protuberances'  are  formed  on  the 
inner  wall  of  capillaries  when  contracting.  By  the 
formation  of  these  protuberances,  the  lumen  becomes 
narrower.  Such  swellings,  said  Golubew  furthermore, 
are  formed  in  certain  places  only.  The  capillaries  there- 
fore are  contractile  at  these  points  only ;  here  alone  can 
they  become  narrower.  I  can  confirm  the  statement  con- 
cerning the  formation  of  swellings,  which,  usually,  are 
not  exactly  opposite  each  other.  The  condition  is  ordi- 
narily such  that  the  swellings  are  somewhat  displaced 
laterally  (as  represented  in  Fig.  3),  and  the  narrowed 
lumen  of  the  vessel  thus  acquires  a  slightly  undulat- 
ing curve.  But  I  must  add  that  the  tube  becomes 
narrower,  not  only  at  the  swollen  places,  but  through- 
out its  whole  length,  although  the  lumen  is  entirely 
closed  at  the  swollen  places  sooner  than  elsewhere.  Moreover,  it  has  seemed 
to  me  as  if  the  portions  of  the  vessel  which  lacked  these  swellings  also  became 
thicker  during  the  process  of  contraction.  I  say  it  has  seemed  so,  because 
the  confirmation  of  a  minute  increase  in  thickness  is  difficult.  Besides  it  i* 
self-evident  that  a  tube  which  becomes  narrower  must  either  form  folds  or 

1  I  cannot  here  go  into  details  and  recite  all  the  subsequent  variations  of  the  experiment. 
8  Archiv  fur  mikrosk.  Anatomie,  Bd.  V. 


10  PATHOLOGY    OF    INFLAMMATION. 

its  walls  must  become  thicker.  But  no  folds  are  to  be  recognized  in  the 
narrowed  tube.  For  this  reason,  therefore,  it  is  already  probable  that  a 
narrowing  of  the  capillaries  is  accompanied  by  a  thickening  of  their  walls. 
Accordingly  we  must  imagine  that  the  narrowing  of  the  capillaries  is  brought 
about  like  that  of  a  passively  distended  elastic  tube. 

This  interpretation,  however,  does  not  yet  give  us  a  clear  insight  into  the 
phenomenon.  We  cannot  in  all  respects  compare  capillaries  in  a  condition 
of  dilatation  with  a  distended  elastic  tube.  The  capillary  tube  can  remain 
distended  even  when  the  blood-pressure  (the  power  which  distends  the  tube) 
is  very  small.  Furthermore,  the  capillary  tube  dilates  of  itself  when  the 
stimulus  which  has  made  it  contract  ceases  to  act;  it  also  dilates  altogether 
without  the  participation  of  the  blood-pressure,  as,  for  example,  in  the 
membrana  nictitans  of  the  frog.  It  is  probable,  too,  that  under  certain 
circumstances  the  dilatation  is  an  active  one ;  that  the  capillary  tube 
aspirates  fluid  during  dilatation.  "Attraction  of  the  blood,"  the  Ancients 
called  it,  and  imagined  that  walls  of  vessels  had  the  power  of  attracting  the 
blood.  We  are  not  aware  of  the  existence  of  such  a  force,  but  know  that 
the  bloodvessels  can  actively  dilate.  In  consequence  of  experiments  made 
with  regard  to  this  question  by  H.  Weber,1  and  then  by  Rynek2  on  the  wreb 
of  the  frog,  and  by  Vulpian3  on  the  blastodermic  membrane  of  the  chick,  it 
has  become  probable  that  the  blood  is  really  aspirated  by  the  dilatation  of 
the  vessels.  Further  researches,  which  wTill  be  discussed  in  the  nejct  section, 
have  also  made  us  acquainted  with  the  nerves  which  excite  such  a  dilatation. 
We  are  therefore  not  allowed  to  compare  (as  regards  the  forces)  the  contrac- 
tion of  a  capillary  with  that  of  a  passively  dilated  elastic  tube. 

But  what  are  the  forces  and  arrangements  on  which  depend  the  active 
contraction  and  the  active  dilatation  ?  More  recent  researches  which  Spina 
and  I4  have  made  on  the  cells  of  glands  are  suited  to  make  us  comprehend 
the  processes  in  the  capillaries.  These  observations  concern  the  glandular 
vesicles.  In  the  skin  of  the  frog  there  are  glandular  vesicles  of  the  simplest 
construction.  Each  gland  consists  of  a  single  acinus  with  an  excretory  duct, 
as  is  indicated  in  Fig.  4.     The  acinus  is  lined  by  a  layer  of  cells,  a  a.     Now 

I  have  already  described  two  condi- 
Fis- 4-  Fis> 5-  tions  of  these  cells  in  my  Manual  of 

Histology.5  These  cells  are  at  times 
so  large  that  they  nearly  fill  up  the 
lumen  of  the  acinus,  and  at  others, 
again,  so  small  that  (as  in  Fig.  4)  they 
merely  form  an  epithelial  lining  for 
the  relatively  large  lumen.  But  now 
Spina  and  I  have  discovered6  that 
these  glandular  cells  become  so  much 
enlarged  under  certain  stimuli  as  to 
till  up  the  lumen  of  the  acinus  (as  in 
Fig.  •">),  and  that  they  become  smaller  again  after  the  stimulus  has  ceased  to 
ad  upon  them. 

Since  this  observation  is  of  general  importance,  I  shall  here  briefly  de- 
scribe how  it  may  be  made.  You  must  cut  out  the  membrana  nictitans  of  a 
living  frog  and  spread  it  out  in  the  aqueous  humor  on  the  stage  of  a  micro- 
scope arranged  for  conducting  electric  stimuli.7     Now  cut  off  with  scissors 

1  MUller'a  Archiv,  1852,  Bd.  I. 

2  Rynek,  Untersuchungen  aus  dem  Inst,  fur  Physiologie  in  Graz.     Leipzig,  1870,  S.  104. 
8  Vulpian,  L^-ons  sur  l'appareil  vaso-moteur,  t.  i.  Quatrieme  lecon. 

*  Wiener  mediz.  Jahrb.  1880.  6  American  edition,  pages  40  and  41. 

6  Mediz.  Jahrbucher,  1.  c.  "  See  Manual  of  Histology,  American  edition,  page  15. 


THE    VASOMOTOR    NERVES.  11 

the  thick  edges,  especially  the  muscular  layer  which  lies  upon  the  lower  third 
of  the  membrane,  where  it  is  inserted  into  the  cutis.  Now  cover  the  speci- 
men with  thin  covering-glass,  and  look,  with  a  high  power,  for  one  of  the 
many  easily-discoverable  glands,  but  one  with  as  large  a  lumen  as  possible.  If 
you  allow  a  few  currents  from  the  induction  coil1  to  pass  through  the  speci- 
men, the  cells  immediately  swell  up  and  soon  fill  the  interior.  If  the  current 
be  too  strong,  the  cells '  do  not  return  again  to  their  former  position ;  the 
gland  dies  in  this  condition,  with  large  cells  occluding  its  lumen.  But  if  the 
current  be  not  too  powerful,  the  cells  soon  again  diminish  in  size  (retract) ; 
the  lumen  of  the  acinus  again  becomes  visible.  As  a  rule,  the  lumen  does 
not  again  become  quite  as  large  as  it  was  before  the  stimulation,  in  the  case 
of  the  excised  membrane.  But  no  matter,  the  stimulus  can  be  reapplied  and 
the  enlargement  of  the  cells  again  observed.  As  a  general  thing,  the  cells  do 
not  react  any  more  after  the  second  or  third  stimulation.  If,  however,  the 
stimulus  be  indirectly  applied,  that  is,  transmitted  through  the  nerves,  we  can 
repeat  the  experiment  very  often  and  always  observe  a  complete  retraction  of 
the  cells.  For  this  purpose  you  must  place  the  web  of  a  living  frog  under 
the  microscope  and  irritate  the  ischiatic  nerve.2 

When  cells  enlarge  they  must  absorb  fluid,  since  an  increase  of  volume 
without  an  increase  of  mass  is  impossible.  By  a  reduction  in  size,  on  the 
other  hand,  fluid  must  be  forced  out  again.  Now  we  have  advanced  the 
hypothesis  that  by  this  absorption  and  expression  of  fluid,  secretion  is  brought 
about.  But  here  this  is  of  minor  importance.  Here  we  are  only  concerned 
with  the  fact  that  cells  have  been  observed  which  actively  enlarge  in  order 
to  narrow  a  lumen,  and  actively  retract  again  in  order  to  enlarge  the  lumen. 
For  this  discovery  proves  that  an  active  contraction  as  well  as  an  active  dila- 
tation of  a  vessel  which  possesses  no  muscular  fibres,  is  not  without  analogy. 

The  Vaso-motor  Nerves. — The  contraction  as  well  as  the  dilatation  of 
bloodvessels  is  regulated  by  the  spinal  cord,  by  means  of  special  nerves  which 
are  called  vaso-motor.  It  is  true  that,  microscopically,  the  special  relation 
between  nerves  and  vessels  is  not  yet  sufficiently  clear.  "We  know  that 
nerves  pass  between  and  along  the  vessels,  but  we  do  not  yet  know  the  termina- 
tions of  nerves  in  the  vascular  walls.  On  the  other  hand,  the  fact  of  the  inner- 
vation of  vessels  has  been  placed  on  a  secure  basis  by  experiment.  The  doctrine 
of  the  vaso-motor  nerves,  founded  on  vivisection  experiments,  may  be  placed 
by  the  side  of  descriptive  anatomy,  as  regards  the  certainty  of  its  fundamental 
laws.  This  doctrine,  too,  forms  a  natural  supplement  to  anatomy ;  for  in  the 
corpse  we  cannot  see  the  final  terminations  of  the  nerves,  and,  up  to  the  pre- 
sent date  at  least,  we  have  not  been  able,  with  the  microscope,  to  distinguish 
the  nerves  in  regard  to  their  function.  The  microscope  gives  us  no  clue  as 
to  whether  a  nerve  is  sensory  or  motor,  whether  it  obe}rs  the  will,  or  whether 
it  supplies  the  vessels  or  the  glandular  cells.  To  all  of  these  questions,  vivi- 
section experiments  give  us  positive  answers.  Experimental  angeioneurology, 
then,  in  view  of  its  great  importance  as  regards  the  circulation,  may,  from 
this  standpoint,  be  regarded  as  one  of  the  most  important  doctrines  in  medi- 
cine. I  would  even  advance  the  opinion  that  no  physiologist,  no  pathologist, 
no  therapeutist,  can  follow  his  profession  in  a  precise  manner  without  being 
familiar  with  this  field  of  inquiry.3     What  I  introduce  here  is,  indeed,  only 

1  The  strength  of  the  current  necessary,  every  one  will  readily  find  out  by  commencing  with 
a  very  weak  one  and  then  increasing  the  strength  until  it  has  effect. 

2  This  irritation  requires  special  precautionary  measures.  See,  on  this  point,  Strieker  and 
Spina,  in  the  article  already  quoted  (Mecliz.  Jahrhiicher,  S.  368). 

3  I  have  added  this  remark  in  order  to  combat  the  view  that  even  this  little  is  superfluous  for 
the  practical  interests  of  surgery. 


12  PATHOLOGY    OF    INFLAMMATION. 

an  incomplete  portion.  Remembering  the  practical  tendencies  of  the  physi- 
cian, I  shall  not  in  those  pages  give  more  than  is  necessary  for  the  compre- 
hension of  the  influence  of  the  nervous  system  on  hyperemia  and  ischsemia. 

The  vaso-motor  nerves  come  from  the  spinal  cord,  as  was  first  recognized 
by  Waller  and  by  Budge.1  They  pass  out  with  the  roots  of  the  spinal  nerves, 
and  then  reach  their  peripheral  terminal  expansions  by  various  routes.  We 
can  arrange  these  routes  into  two  main  groups : — 

A.  First  Main  Group. — A  large  majority  of  the  vaso-motor  nerves  leave 
the  spinal  nerves  with  the  rami  communicantes,  and  with  the  latter  enter  the 
great  sympathetic.  They  run  a  short  distance  upward  or  downward  in  the 
great  sympathetic,  and  then  leave  it  in  two  ways:  (1)  As  independent 
branches  of  the  great  sympathetic,  as  they  are  represented,  for  example,  by 
the  splanchnic  nerves,  which,  I  may  remark,  contain  the  principal  mass  of 
the  vaso-motor  nerves  for  the  abdominal  organs.  (2)  After  they  have 
ascended  or  descended  a  distance  in  the  great  sympathetic,  they  return  again 
by  means  of  rami  communicantes  to  the  spinal  nerves,  and  together  with  these 
reach  the  parts  which  they  supply.  This  arrangement  holds  good  for  the 
skin,  the  muscles,  and  the  bones.  Thus,  for  instance,  the  vaso-motor  nerves 
of  the  foot  leave  the  spinal  cord  with  a  series  of  roots  of  the  dorsal  and  lum- 
bar nerves,  descend  in  the  great  sympathetic,  leave  it  deep  in  the  pelvis,  and 
reach  and  enter  the  sciatic  nerve  by  means  of  a  small  communicating  filament. 

B.  Second  Main  Grovp. — A  considerable  number  of  vaso-motor  nerves  do 
not  enter  the  sympathetic  at  all,  but  go  directly  into  the  corresponding  spinal 
nerves,  and  reach  their  terminal  expansions  with  them.  Thus,  the  hind-paw 
of  the  dog  receives  both  the  previously  mentioned  nerves,  which  enter  the 
sympathetic,  and,  on  the  other  hand,  the  last-mentioned  nerves,  which  come 
directly  from  the  spinal  cord  with  the  roots  of  the  sciatic,  and  reach  the  paw 
with  the  branches  of  that  nerve.  It  will  be  convenient  for  the  further  dis- 
cussion of  this  subject  to  designate  the  last-mentioned  class  as  the  direct,  and 
the  first-mentioned  as  the  indirect  supply. 

The  circumstance  that  a  peripheral  region  of  the  body  receives  its  vaso- 
motor nerves  from  many  spinal  roots,  plays  a  part  (as  I  shall  show  imme- 
diately) in  the  recovery  from  hyperemia.  In  order  to  illustrate  my  meaning 
for  the  present  by  a  comparison,  we  need  only  consider  the  case  of  a  man 
who  draws  his  income  from  many  sources;  such  a  man  need  not  suffer  hunger 
though  one  or  several  sources  be  exhausted.  To  support  this  comparison  by 
another  (imaginary)  case  from  practice,  let  us  suppose  that  the  lumbar  por- 
tion of  the  spinal  cord  lias  been  completely  separated  from  the  dorsal  portion 
by  a  projectile,  but  that  the  projectile  has  remained  in  the  spinal  canal,  and 
has  done  no  further  damage,  the  great  sympathetic  being  accordingly  unin- 
jured. The  lower  extremities  will  now  be  completely  paralyzed  and  insensi- 
tive, because  all  the  nerves  which  give  them  sensation  and  voluntary  motion 
have  been  divided.  This  condition  is  incurable.  After  the  injury,  moreover, 
the  lower  extremities  are  warm  (hypersemic),  since  a  considerable  number  of 
nerves  have  been  divided,  which  formerly  gave  a  certain  tone  to  the  blood- 
vessels. But  these  divided  vaso-motor  nerves  were  not  the  only  ones  which 
maintained  the  vascular  tone  in  the  limbs,  for  I  have  said  that  the  sympa- 
thetic was  uninjured.  Now,  as  before,  vaso-motor  nerves  from  this  penetrate 
the  sciatic  vaso-motor  nerves  which  have  not  been  at  all  injured  by  the  pro- 
jectile.     In   fact,  the  hypersemia  of  the  lower  extremities  passes  away;  they 

1  1S53.     Quoted  from  Vulpian's  Leeons  sur  I'appareil  vaso-moteur,  t.  i.  p.  23. 


THE   VASOMOTOR   NERVES.  13 

again  become  cool ;  they  must,  accordingly,  have  again  acquired  a  vascular 
tone  in  spite  of  the  paralysis  and  loss  of  sensation.  I  consider  this  case  only 
hypothetically  in  man,  because  I  have  only  experimented  on  dogs.  But  I 
know  that  persons  whose  spinal  cords  have  sustained  complete  lesions  of  con- 
tinuity in  the  lower  dorsal  region,  have  cold  lower  extremities  during  the 
course  of  the  disease.  Whether  that  which  has  been  proved  with  regard  to 
the  hind-paw  of  the  dog  holds  good  for  all  other  regions  of  skin  and  muscle, 
has  not  yet  been  ascertained;  but,  for  reasons  which  I  cannot  explain  here,  it 
is  probable  that  elsewhere  this  condition  is  also  present.  With  reference  to 
man,  I  hope  that  clinical  observations  will  clear  up  this  question. 

The  vaso-motor  nerves  are  divided  according  to  their  function  into  two 
groups :  those,  irritation  of  which  contracts  the  vessels,  and  those,  irritation 
of  which  dilates  them.  The  former,  called  vaso-con stridors,  normally  produce 
a  certain  tone  of  the  bloodvessels,  and  hence  exert  a  continual  influence  on 
the  distribution  of  the  blood  and  on  the  fulness  of  the  bloodvessels.  In  the 
supposed  case  of  injury  of  the  spinal  cord  and  subsequent  curable  hyperemia, 
I,  of  course,  had  in  mind  only  the  vaso-constrictors.  Their  antagonists,  the 
vaso-dilators,  do  not,  as  far  as  at  present  known,  exert  a  continual  influence; 
they  act  under  certain  conditions  only,  when  they  receive  a  special  stimulus. 
The  vaso-constrictors  are  dominated  over  by  ganglionic  cells  (centres)  of  the 
spinal  cord,  and  especially  of  the  medulla  oblongata,  which  plays  so  important 
a  part  in  this  function,  that  it  for  a  long  time  was  supposed  to  contain  all  the 
centres  of  the  vaso-motor  nerves,  on  which  it  was  believed,  on  the  other  hand, 
that  the  spinal  cord  had  no  influence  at  all ;  but  this  supposition  has  not  been 
verified.  I,  in  particular,  have  shown1  that  on  the  boundary  line  between 
the  cervical  and  dorsal  portions  of  the  cord  there  are  also  located  important 
centres  for  the  vaso-constrictors. 

The  nerve-centres  which  dominate  the  constrictors  also  control  the  blood 
pressure.  This  fundamental  law  of  physiology  we  owe  to  Carl  Ludwig  and 
his  pupil  Thiry.2  When  the  nerve-centres  send  out  powerful  impulses,  and 
the  vessels  consequently  become  very  narrow,  the  blood  cannot  flow  out  of 
the  aorta  readily.  But  since  the  heart  pumps  fresh  quantities  of  blood  into 
the  aorta,  the  tension  of  the  walls  (i.  e.,  the  blood  pressure  in  the  aorta)  must 
rise.  When,  however,  the  nerve-centres  do  not  send  any  impulses,  or  only 
weak  ones,  then  the  bloodvessels  dilate,  the  blood  flows  out  of  the  aorta 
readily,  and  its  tension  must  decrease.  Exactly  the  same  thing  occurs  here 
as  in  every  system  of  pipes  or  rivers.  When  the  channels  of  discharge  are 
obstructed,  the  pressure  on  the  lateral  walls  above  the  seat  of  the  obstruction 
rises.  A  second  fundamental  law,  the  enunciation  of  which  we  likewise  owe 
to  C.  Ludwig3  and  his  pupils,  tells  us  that  the  bloodvessels  of  the  abdominal 
viscera  are  the  principal  regulators  of  the  blood-pressure.  The  bloodvessels 
of  the  abdominal  viscera,  that  is  to  say,  have  so  great  a  capacity,  and  by 
dilatation  and  contraction  can  increase  or  diminish  their  contents  to  such  an 
extent,  that  they  act  like  a  mighty  reservoir.  If  this  reservoir  is  wide  open, 
it  can  contain  so  large  a  portion  of  the  total  amount  of  blood  that  the  rest  of 
the  organism  becomes  anaemic.  An  animal  with  complete  paralysis  of  the 
vaso-motor  nerves  of  the  abdominal  viscera,  therefore,  bleeds  to  death,  as  it 
were,  into  its  own  abdominal  bloodvessels. 

The  nerves  which  influence  these  vessels  lie  principally,  as  already  remarked, 

1  Wiener  mediz.  Jahrb.  1878.  Still  earlier,  one  of  my  pupils  (Schlesinger),  and  at  the  same 
period  Vulpian,  had  shown  that  it  could  not  be  the  medulla  oblongata  alone  which  controlled 
the  vaso-constrictors.  The  full  proof,  however,  of  the  existence  of  such  centres  in  the  spinal 
cord  was  brought  forward  in  my  paper  just  quoted. 

2  Wiener  Sitzungsberichte,  18(54,  Bd.  49. 

8  Arbeiten  aus.  d.  physiolog.  Anstalt  zu  Leipzig,  1867  u.  ff. 


14  PATHOLOGY   OF   INFLAMMATION. 

in  the  splanchnic  nerves.  Therefore,  when  the  splanchnics  are  divided,  an 
intense  hyperemia  of  the  abdominal  viscera  is  produced,  accompanied  by  a  fall 
of  the  blood-pressure  and  an  isehaemia  of  the  remaining  organs.  The  splanch- 
nics, as  I  have  likewise  already  remarked,  are  branches  of  the  great  sympathetic, 
and  before  entering  the  sympathetic  leave  the  spinal  cord  with  the  roots  of 
the  upper  dorsal  nerves.  If  we  divide  the  spinal  cord  low  down,  at  about  the 
border  of  the  dorsal  and  lumbar  portions,  the  points  of  origin  of  the  splanchnics 
scarcely  suffer  at  all.  An  animal  thus  injured  is  paralyzed  and  insensitive  in 
its  hind-legs,  but  otherwise  may  feel  well,  as  far  as  the  condition  of  the 
wound  permits.  Indeed  such  an  animal,  as  a  rale,  becomes  perfectly  well  and 
lively  again,  and  differs  externally  from  a  healthy  animal  only  in  dragging 
its  hind-legs.  It  is  quite  different  if  the  division  be  made  higher  up,  about 
the  region  of  the  second  or  third  dorsal  vertebra.  In  consequence  of  such  a 
wound,  all  the  vaso-motor  nerves  of  the  abdominal  viscera  become  separated 
from  their  central  ganglia  ;  from  those  on  the  border  between  the  cervical  and 
dorsal  portions  of  the  qord,  as  well  as  from  those  in  the  medulla  oblongata 
(see  page  13).  In  consequence  of  this  there  ensues  such  an  intense  hypere- 
mia of  the  abdominal  viscera,  and  such  a  considerable  fall  in  the  blood-pres- 
sure, that  an  ischemia  of  the  other  organs  arises  which  may  prove  fatal. 

It  is  not,  however,  without  importance  for  the  physician  to  learn  that,  even 
after  such  a  division  of  the  spinal  cord,  the  abnormal  distribution  of  the 
blood  is  not  always  fatal;  since  the  vaso-motor  nerves  of  the  abdominal 
viscera  still  remain  connected  with  some  centres  which  are  located  farther 
down  in  the  dorsal  portion  of  the  spinal  cord,  and  certainly  reach  as  far  as 
the  region  of  the  lower  dorsal  vertebrae.  I  have  ascertained  this  by  the 
following  series  of  experiments : — 

If  in  a  dog  we  divide  the  cervical  portion  of  the  cord  just  below  the  medulla  oblon- 
gata, the  animal  soon  ceases  to  breathe,  because  the  nervous  centres  of  respiration  in 
the  medulla  oblongata  (with  which  Legallois  and  subsequently  Flourens  have  made  us 
acquainted)  are  separated  from  the  peripheral  nerves  of  respiration.  But  if  we  employ 
artificial  respiration,  as  is  generally  the  practice  in  vivisection  experiments,  we  can  keep 
up  the  circulation  and  heart-beats  respectively  for  hours.  True,  the  blood-pressure  is 
low,1  because  important  vaso-motor  centres  of  the  medulla  oblongata  are  disconnected 
from  their  peripheral  nerves ;  but  the  important  vaso-motor  centres  at  the  lower  border 
of  the  cervical  portion  still  perform  their  function,  for,  as  already  observed,  the  incision 
is  made  high  up  in  the  neighborhood  of  the  atlas.  Now  I  have  completely  extirpated  the 
cervical  portion  of  the  cord,  from  the  medulla  oblongata  down  to  the  fifth  cervical  vertebra. 
Such  an  operation  causes  some  hemorrhage,  in  spite  of  all  precautions  ;  the  animal 
sutlers  from  this  hemorrhage  ;  but  the  influence  on  the  blood-pressure  is  trifling.  But 
if  I  continue  this  extirpation  down  to  the  first  dorsal  vertebra,  the  blood-pressure  sinks 
suddenly  to  an  extremely  low  level  (about  20  mm.  mercury).  But  the  circulation  still 
continues.  Yet,  as  soon  as  I  proceed  with  the  extirpation  beyond  the  first  dorsal  ver- 
tebra, the  blood-pressure  falls  to  nearly  zero,  and  soon  the  heart-beats  cease. 

Thai  it  is  really  the  accumulation  of  the  blood  in  the  abdominal  viscera 
which  causes  death,  can  be  demonstrated  by  an  experiment  which  we  also 
owe  to  C.  Ludwig,  and  which,  it  scorns  to  me,  is  of  the  greatest  practical 
importance.  If  we  knead  the  abdomen  vigorously  at  the  time  when  the 
heart-beats  are  about  to  cense,  these  immediately  become  more  energetic. 
For  by  this  kneading  a  portion  of  the  blood  which  has  accumulated  in  the 
abdominal  veins  is  forced  (by  the  pressure  of  the  hands)  into  the  heart,  and 
the  ;i<-ii<Mi  of  the  latter  is  excited.  A  knowledge  of  this  procedure  is  impor- 
tant for  the  physician,  because,  even  in  the  ease  of  a  severe  hemorrhage,  he 
<an  strengthen  the  pulse  again,  if  it  has  become  thready,  by  kneading  the 

1  From  about  100  mm.  mercury,  the  normal  height,  it  sinks  to  about  CO  mm.  mercury. 


THE    VASOMOTOR    NERVES.  15 

abdomen.  In  cases,  therefore,  where  the  abdominal  viscera  are  normal  and 
where  there  is  no  damage  likely  to  be  caused  by  vigorous  kneading ;  where, 
furthermore,  everything  depends  on  a  speedy,  even  though  passing,  assist- 
ance ;  in  such  cases,  I  say,  the  introduction  of  even  small  quantities  of  blood, 
which  are  under  all  circumstances  present  in  the  abdominal  veins,  may  be  of 
considerable  value.  There  are  instances  of  hemorrhage  in  which  the  indi- 
viduals can  recover  of  themselves  by  the  substitution  of  lymph,  if  we  only 
ward  off  the  momentary  danger  of  death  immediately  after  the  hemor- 
rhage. 

I  have  already  remarked  that,  when  the  extirpation  of  the  spinal  cord 
proceeds  beyond  the  upper  dorsal  vertebra?,  the  pressure  falls  to  zero  and  the 
heart-beats  cease.  But  this  only  holds  good  for  adult  animals.  I  have  extir- 
pated the  entire  spinal  cord  of  young  dogs  (about  two  months  old),  and  yet 
the  circulation  continued  (during  uninterrupted  artificial  respiration),  so  that 
I  was  enabled  to  note  the  pressure,  although  it  was  exceedingly  low  (about 
10-15  mm.  mercury). 

The  hyperemia  of  the  abdominal  viscera  which  is  produced  by  paralysis 
of  the  vaso-motor  nerves  is  an  active  one.  Now  I  have  already  said  that  an 
active  hyperemia  involves  an  acceleration  of  the  blood-current  in  the  hyper- 
remic  district.  But  we  must  consider  here  that  the  hyperemia  is  of  vast 
extent,  involving  as  it  does  all  the  abdominal  viscera.  The  moment  this 
great  reservoir  becomes  widened,  the  blood  must  flow  in  more  rapidly,  else 
how  is  it  possible  for  the  tension  in  the  aorta  to  suddenly  decrease  ?  But, 
when  the  reservoir  is  filled,  the  heart  becomes  poor  in  blood.  The  right 
ventricle  is  inadequately  supplied ;  little  blood  flows  into  the  left  ventricle ; 
only  a  small  amount  of  blood  is  forced  into  the  aorta.  Consequently  the 
rapidity  of  the  arterial  blood-current  in  general  must  be  decreased,  and  it 
may  sink  to  zero.  For,  if  the  heart  forces  no  blood  at  all  into  the  aorta,  the 
circulation  stops. 

I  call  the  active  hyperemia  which  is  produced  by  paralysis  of  the  vaso- 
constrictors a  hyperemia  of  paralysis,  in  contradistinction  to  the  hyperemia 
caused  by  irritation  of  the  vaso-dilators,  which  I  have  termed  hypercemia  of 
irritation.  The  hyperemia  of  irritation  and  the  vaso-dilators,  respectively, 
were  discovered  by  Claude  Bernard  in  1858.  Claude  Bernard1  has  shown 
that  the  submaxillary  gland  of  the  dog  acquires  a  bright-red  color  by  an 
irritation  of  its  nerves,  and  that,  at  the  same  time,  the  blood  which  flows 
from  the  incised  vein  of  the  gland  is  of  a  brighter  red,  and  more  abundant, 
than  it  was  before  the  irritation.  At  a  later  period,  Eckhard2  found  similar 
vaso-motor  nerves  supplying  the  corpora  cavernosa  of  the  dog's  penis ;  and, 
still  later,  Goltz3  discovered  them  in  the  sciatic  nerve  of  the  dog.  But  in 
this  nerve  they  lie  adjacent  to  their  antagonists,  the  vaso-constrictors.  Ac- 
cordingly, when  we  irritate  the  sciatic  artificially,  both  kinds  are  acted  upon, 
and  the  effect  is,  as  a  rule,  insignificant,  or  altogether  fails  to  appear.  Special 
circumstances  are  required  by  means  of  which  one  of  the  antagonists — in  this 
instance  the  constrictors — may  be  made  ineffective.4 

This  is  the  case  if  we  first  divide  the  sciatic  and  make  the  chief  experiment  several 
days  later.  If,  several  days  after  the  division,  we  draw  the  peripheral  stump  out  of 
the  wound  and  irritate  it,  we  learn  that  the  irritation  excites  only  the  vaso-dilators  ; 
the  corresponding  paw  immediately  becomes  warmer,  and  cools  off  again  as  soon  as  the 
stimulus  ceases.     But  I  must  observe  that  this  experiment,  performed  on  dogs  other- 

1  Lecons,  Syst&me  nerveux,  1858. 

2  Beitrage  zur  Anatomie  und  Phvsiologie,  Bd.  III.  1863. 

3  Piliiger's  Archiv,  1874,  Bd.  8. 

•  These  circumstances  have  been  ascertained  by  Ostroumoff,  a  pupil  of  Heidenhain  (Pfliigers 
Archiv,  Bd.  12),  and  by  myself. 


16  PATHOLOGY    OF    INFLAMMATION. 

wise  healthy,  is  not  very  convincing.  For,  if  we  divide  the  sciatic,  the  corresponding 
paw  becomes  actively  hyperaemic  (on  account  of  the  paralysis  of  the  constrictors). 
But  this  hyperemia  of  paralysis  lasts  a  long  time,  because  all  the  constrictors  for  the 
paw  are  already  united  in  the  sciatic.  It  is  even  questionable  whether  such  a  hyper- 
emia is  recovered  from  at  all  in  older  animals.  At  all  events,  the  hyperemia  is  still 
very  marked  on  the  third  and  fourth  days  after  the  division  of  the  sciatic.  Accord- 
ingly, irritation  of  the  dilators  accomplishes  but  little  if  the  vessels  are  already  very 
wide. 

But  if  we  wait  several  weeks  before  irritating,  the  nerve  in  the  mean  time  completely 
degenerates.  I,  therefore,  make  the  experiment  as  follows  :  I  chloroform  a  young  dog, 
and  then  divide  his  spinal  cord  in  the  region  of  the  last  dorsal  vertebra.  Both  hind- 
paws  are  now  hyperaemic  ;  but  this  hyperemia  improves  in  a  few  days,  because  the 
hind-legs  and  the  sciatics  respectively  receive  also  vaso-constrictors  from  the  dorsal 
portion  of  the  cord,  through  the  sympathetic. 

I  have  designated  this  recovery  as  "  recovery  by  collateral  innervation  ;"  using 
the  term  "collateral"  because  the  condition  is  analogous  to  a  collateral  circu- 
lation. If  in  any  region  the  main  channel  of  the  blood  is  ligatured,  a  lateral 
channel,  which  is  sufficient  for  the  nutrition  of  the  entire  region,  is  gradually 
formed  by  the  dilatation  of  small  lateral  branches.  These  small  branches 
must,  therefore,  adapt  themselves  to  their  new  function  by  increased  growth. 
Now  we  see  a  similar  condition  of  things  in  the  case  of  the  nerves. 

In  the  region  of  the  last  dorsal  vertebra,  the  spinal  cord  contains  the  main  mass  of 
the  vaso-constrictors  for  the  paw.  These  are  now  divided,  and  the  remaining  branches, 
which  leave  the  main  mass  above  the  site  of  incision,  do  not  at  first  suffice  to  maintain 
the  tone  of  the  bloodvessels.  But  these  higher  branches  increase  in  strength  in  the 
course  of  a  few  days,  and  thus  the  hyperemia  disappears.  I  have  advanced  the  follow- 
ing proof  for  this  interpretation  :  After  the  hyperemia  of  the  paw  has  disappeared,  I 
again  anesthetize  the  dog,  and  then  again  divide  the  spinal  cord,  but  higher  up,  in 
the  neighborhood  of  about  the  fourth  and  fifth  dorsal  vertebre.  Thereby  the  hind-paws 
once  more  become  hyperemic.  But  if  an  incision  through  the  dorsal  portion  can  now 
still  cause  hyperemia  of  the  hind-paws,  then  the  tone  of  their  bloodvessels,  after  the 
first  healing,  must  absolutely  have  depended  upon  nerves  divided  by  the  knife  in  this 
(higher)  region;  upon  nerves  which  left  the  spinal  cord  above  the  site  of  the  lower 
(original)  incision. 

I  now  return  once  more  to  the  argument  regarding  the  vaso-dilators  of  the  sciatic. 
I  have  divided  the  spinal  cord  in  the  region  of  the  last  dorsal  vertebra,  and  have  waited 
until  the  hyperemia  of  the  hind-paws  has  disappeared  again.  I  now  divide  the  sciatic  ; 
this  can  be  done  without  anesthesia,  because  the  hind-legs  of  the  animal  are  insensi- 
tive. Just  after  the  division,  however,  the  corresponding  paw  becomes  warm  again, 
because  now  also  those  constrictors  are  divided  which  caused  recovery  by  collateral 
innervation.  But  even  this  hyperemia  improves,  especially  in  winter,  if  the  animal 
is  kept  in  an  unhealed  room.1  If,  now,  I  provide  the  paw  in  cpiestion  with  a  suitable 
thermometer,8  and  wait  until  the  mercury  stops  rising,  open  the  wound  on  the  thigh, 
draw  out  the  peripheral  stump  of  the  sciatic,  and  apply  an  electric  stimulus  (by  means 
of  moderately  strong  induction-currents),  the  column  of  mercury  soon  begins  to  rise. 
In  such  cases  I  have  observed  rises  of  temperature  from  20°  to  37°  Celsius  [G8°  to 
98  '.6  Fahr.]  ;  and,  indeed,  the  rise  begins  a  few  seconds  after  commencement  of  the 
irritation,  and,  if  the  latter  be  sufficiently  strong,  reaches  its  maximum  in  a  few 
minutes.     Several  minutes  after  stoppage  of  the  irritation,  the  mercury  begins  to  fall. 

1  I  do  not  know  the  cause  of  this  improvement.  At  all  events,  I  must  mention  that  I  per- 
formed  these  experiments  <»n  quite  young  animals,  in  which,  as  already  remarked  (page  15),  a 
certain  tone  of  the  bloodvessels  is  maintained,  with  or  without  any  innervation.  Since  the 
recovery  indicated  in  the  text  does  not  take  place  in  animals  whose  spinal  cord  is  intact,  I 
suspect  that  in  animals  sick  in  consequence  of  division  of  the  spinal  cord,  the  blood-pressure  is 
below  the  normal,  and  that  the  vessels  can  thus  acquire  their  tone  again  more  readily.  But  this 
explanation  is  neither  Sufficient  nor  satisfactory. 

2  Short,  cylindrical,  mercurial  thermometers  are  introduced  between  the  toes. 


THE   VASOMOTOR   NERVES.  17 

In  consequence  of  these  observations,  we  may  conclude  that  in  the  sciatic 
there  are  both  constrictors  and  dilators.  I  shall,  however,  repeat  the  entire 
train  of  thought  which  leads  to  this  conclusion.  In  consequence  of  the  pre- 
sence of  constrictors,  the  paws  become  warm  when  we  divide  the  sciatica. 
In  consequence  of  the  presence  of  both  constrictors  and  dilators,  moreover,  the 
irritation  of  the  peripheral  stump,  immediately  after  the  division,  is  without 
effect.  If  there  were  only  constrictors  present,  their  irritation  would  neces- 
sarily cause  a  narrowing  of  the  bloodvessels,  and  hence  a  cooling  of  the  parts ; 
but  this  does  not  take  place,  or  does  so  only  in  a  slight  degree.  We  therefore 
conclude  that  there  are  also  antagonists  (dilators)  present,  which  are  likewise 
irritated,  and  that  hence  no  effect  is  produced.  And  we  furthermore  suspect 
that,  after  the  division,  the  constrictors  either  degenerate  or  lose  their  irrita- 
bility sooner  than  the  dilators,  wherefore  the  stimulus  is  now  responded  to 
only  by  the  dilators.  However,  this  proof  is  not  altogether  reliable.  One 
could  reply  that  the  sciatic  possesses  no  vaso-dilators ;  that  the  constrictors 
are  only  not  irritable,  immediately  after  the  division  of  the  sciatic ;  that  on 
this  account,  and  not  because  antagonists  are  present,  is  the  stimulus  ineffec- 
tive. After  a  few  days,  however,  the  constrictors  undergo  some  alteration, 
and  now  act  in  a  manner  quite  different  from  that  of  their  normal  condition. 

This  objection  is  not  plausible ;  but  it  is  admissible.  Now  the  hypothesis 
concerning  the  vaso-dilators  is  of  the  greatest  importance  for  pathology.  We 
must  take  this  hypothesis  into  account,  and  it  is  therefore  important  to  bring 
forward  direct  proof  of  the  existence  of  vaso-dilators  in  the  sciatic.  I  have, 
indeed,  succeeded  in  so  doing.  I  found  that  those  posterior  spinal  roots 
which  entered  the  sciatic  directly,  also  contained  the  direct  vaso-dilators 
(see  page  12)  for  the  paw,  but  no  vaso-constrictors.  Here,  therefore,  I  had 
nerves  before  me,  the  irritation  of  which  in  a  fresh  condition,  immediately 
after  their  division,  caused  dilatation  of  the  bloodvessels. 

In  order  to  make  this  experiment,  I  likewise  first  divide  the  spinal  cord  in  the 
region  of  the  last  dorsal  vertebra,  and  let  the  animal  live  until  the  hind-paws  again 
become  cool.  Then,  without  narcotizing  the  animal,  I  can  break  open  the  lumbar 
vertebrae  and  expose  the  spinal  roots  to  such  an  extent  that  I  can  easily  divide  and 
irritate  them.  In  these  parts  the  animal  is  perfectly  insensitive ;  it  takes  food  from 
the  hand  of  the  attendant  while  I  am  dividing  the  nerves.  I  employ  mechanical 
irritation  by  means  of  the  application  of  ligatures,  because  electrical  irritation  of  nerves 
which  lie  in  such  proximity  to  the  spinal  cord,  that  is  to  say,  in  such  proximity  to 
many  other  vaso-motor  nerves,  is  uncertain,  affecting  also  the  other  nerves,  and,  there- 
fore, not  giving  distinct  results.  Mechanical  irritation,  on  the  other  hand,  practised 
with  care  and  by  steady  hands,  is  entirely  reliable.  In  fact,  all  the  experiments  which 
I  have  made  in  this  direction  during  a  series  of  years  have  uniformly  given  the  same 
result.  There  have  always  been  either  one  or  two  roots  of  the  sciatic1  which  have 
contained  the  main  mass  of  vaso-dilators,  the  mechanical  irritation  of  which  lias 
accordingly  produced  a  considerable  elevation  of  temperature  in  the  corresponding  paw. 

The  fact  that  vaso-dilators  are  contained  in  the  posterior  sensory  roots  is 
not  of  small  importance  for  the  doctrine  of  hyperemia.  We  are  thus  enabled 
to  explain  a  series  of  important  pathological  phenomena. 

It  is  known  that  neuralgias  are  frequently  accompanied  by  hyperemia  of 
the  painful  parts.  Now  this  phenomenon  is  understood  if  we  know  that  the 
sensitive  spinal  roots  contain  vaso-dilators.  Irritation  of  certain  sensory 
roots  must  necessarily  cause  pain  and  hyperemia  at  the  same  time.  Pain 
and  hyperemia  must  also  coincide  as  regards  location  in  the  case  of  such  an 
irritation.  For  we  locate  the  painful  spot  at  the  peripheral  end  of  the  nerve 
the  trunk  of  which  is  irritated,  while  at  the  same  spot  the  vaso-dilators 

•  Wiener  raediz.  Jalirbiicher,  1S77-1878. 
VOL.  I. — 2 


18  PATHOLOGY    OF   INFLAMMATION. 

which  accompany  the  root  of  that  sensitive  nerve  are  distributed.  Further- 
more, it  has  become  known  by  the  researches  of  Baerensprung,1  which  have 
since  been  frequently  corroborated,  that  in  herpes  zoster  the  intervertebral 
ganglia  are  diseased.  Since  the  intervertebral  ganglia  are  situated  on  the 
posterior  sensory  roots,  and  since,  moreover,  I  have  likewise  caused  hypere- 
mias by  an  irritation  of  these  ganglia,  this  discovery  of  Baerensprung  is  easily 
understood.  It  is  quite  comprehensible  that  neuralgia  and  an  inflammatory 
eruption  may  be  connected  with  a  pathological  process  in  the  intervertebral 
ganglion. 

This  fact  of  the  common  course  of  sensory  and  vaso-dilator  nerves  is  finally 
suited  to  explain  the  connection  between  local  inflammatory  irritation  on 
the  one  hand,  and  the  inflammatory  hyperemia  and  the  pain  which  accom- 
pany the  process  on  the  other.  It  was  formerly  supposed  that  the  inflam- 
matory irritation,  inasmuch  as  it  implicated  the  sensory  nerves,  caused  pain 
by  means  of  their  centripetal  conduction,  and  at  the  same  time  excited  reflex 
action.  Accordingly,  it  was  said,  inflammatory  hyperemia  is  produced  by 
reflex  action.  But  this  assumption  had  no  solid  foundation.  If  every 
inflammatory  irritation  must  first  be  conducted  to  the  central  nervous 
system  in  order  to  produce  hyperemia  (by  reflex  action),  I  cannot  see  why 
this  hyperemia  appears  just  where  the  irritation  acts.  If  powerful  irritation 
produces  reflex  action,  the  reflex  movements  are  not  confined  to  the  seat  of 
the  irritation.  But  inflammatory  l^peraemia  always  appears  at  the  seat  of 
irritation  only.  "  Ubi  stimulus  ibi  affluxus"  is  the  old  rule,  which  holds  good 
for  weak  as  well  as  for  powerful  inflammatory  irritation.  It  is  therefore 
probable  that  inflammatory  hyperaemia  is  a  direct  local  consequence  of  the 
local  irritation.  It  is  probable  that  the  local  irritation  excites  at  the  same 
time  both  the  sensory  nerves  and  the  vaso-dilators  of  the  implicated  region. 
Whilst  the  former  cause  pain  by  means  of  centripetal  conduction,  the  latter 
produce  a  dilatation  of  the  vessels  by  means  of  centrifugal  conduction.2 


Hyperemia  of  Irritation  and  of  Paralysis. 

Hyperaemia  of  irritation  is  distinguished  from  hyperaemia  caused  by 
paralysis  of  the  constrictors,  in  the  first  place,  by  its  duration.  The 
hyperaemia  of  irritation  lasts  but  a  few  minutes  after  the  irritation.  Ex- 
periment teaches  us  that  the  organs,  after  interruption  of  the  irritation,  soon 
become  pale  again.  The  hyperaemia  of  paralysis,  on  the  other  hand,  lasts 
until  the  vessels  have  again  acquired  tone,  and  this  may  require  several  days 
or  weeks,  according  to  the  number  of  paralyzed  nerves.  More  than  that,  as 
already  remarked  (page  16),  I  consider  it  questionable  whether  hyperaunia 
of  paralysis  can  be  recovered  from  at  all  in  older  animals,  and  after  division 
of  all  the  constrictors.  Meanwhile  we  must  not  consider  every  prolonged 
hyperaemia  as  one  caused  by  paralysis.  If,  as  in  the  case  of  inflammatory 
foci,  I  lie  irritation  continue,  the  hyperaemia  of  irritation  can  also  continue. 
It  is,  moreover,  possible  that  vessels  which  remain  very  widely  dilated  for  a 
long  lime,  in  consequence  of  repealed  or  lasting  irritation,  can  become  nar- 
rower again  only  slowly  and  gradually. 

Observations  on  man  permit  us  to  suspect  that  the  hyperemias  of  irritation 

1  The  literature  of  this  subject  may  be  found  in  Kaposi's  article,  Zur  Aetiologie  des  Herpes 
Zoster.     Wiener  mediz.  Jahrb.  J  876,  S.  55. 

2  A  problem  as  y*'t  unsolved  is  the  hypersemia  which  accompanies  keratitis.  The  cornea  has 
sensory  nerves  ;  it  may,  therefore,  also  have  vaso-dilators.  Bnt  we  should  have  to  assume 
thai  these  vaso-dilators  penetrated  the  cornea  with  the  sensory  nerves,  and  did  not  terminate 
there,  but  returned  to  the  vessels  of  the  margin.     For  this,  however,  we  have  as  yet  no  proof. 


THE   MECHANICAL    HYPEREMIAS.  19 

also  play  an  important  part  even  in  health.  The  flushing  of  the  face  which 
accompanies  outbreaks  of  anger  is  probably  a  hyperemia  of  irritation.  For, 
at  the  same  time,  the  nerves  of  the  muscles  of  the  trunk  also  become  stimu- 
lated ;  excited  persons  gesticulate  violently,  and  contract  the  muscles  of  the 
face,  and  of  speech.  The  glandular  nerves  also  become  excited,  for  in  great 
passion  the  secretion  of  saliva  is  increased.1  Finally,  this  circumstance  is 
still  to  be  considered,  namely,  that  the  hyperemia  diminishes  as  soon  as  the 
person  calms  down. 

The  hyperemias  which  are  associated  with  the  functions  of  organs  we  may 
also  presume  to  belong  to  this  class.  Respecting  the  salivary  glands,  we 
know  that  irritation  of  the  glandular  nerves  (discovered  by  C.  Ludwig) 
always  causes  an  active  hyperemia,  and,  at  the  same  time,  an  increased  secre- 
tion. But  I  have  already  remarked  that  this  hyperemia  is  produced  by 
vaso-dilators.  It  is  accordingly  most  plausible  to  suppose  that  the  hyperemia 
which  is  associated  with  the  function  of  glands  in  general,  is  a  hyperemia  of 
irritation.  For  the  other  organs,  it  is  true,  we  have  no  such  positive  data  as 
in  the  case  of  the  glands.  But  it  is  more  probable  than  an  irritation  of  the 
dilators  is  connected  with  the  function  of  an  organ  (which  requires  stimuli  in 
order  to  perform  this  function),  than  that  a  paralysis  of  the  constrictors  is 
associated  with  that  function  or  with  such  stimuli.  That  the  erection  of  the 
penis  is  produced  (according  to  a  discovery  of  Eckhard)  by  irritation  of  vaso- 
dilators, I  have  mentioned  previously.  According  to  our  present  knowledge, 
it  is,  therefore,  not  improbable  that  all  passing,  active  hyperemias  which 
arise  normally  in  life,  and  many  pathological  fluxions,  are  caused,  not  by 
paralysis  of  the  constrictors,  but  by  irritation  of  the  dilators. 


The  Mechanical  Hyperemias. 

It  is  an  open  question  whether  hyperemias  can  arise  without  vaso-motor 
nerves  being  concerned  in  their  production.  The  various  forms  of  hyperemia 
due  to  mechanical  causes,  which  have  been  enumerated  by  pathologists,  can- 
not be  advanced  as  an  argument  here.  Physicians  have  named  the  various 
forms  of  hyperemia  after  their  causation  and  their  phenomena;  they  have 
not  at  all  taken  into  account  whether  vaso-motor  nerves  are  implicated  or 
not,  especially  because  they  have  had  no  knowledge,  or  very  inadequate 
knowledge,  of  these  nerves.  However,  in  one  direction,  physicians  have  pro- 
perly judged  of  the  mechanical  conditions.  The  ultimate  cause  of  all  hyper- 
emias of  stagnation  and  of  paralysis,  is  of  a  mechanical  nature.  If  the  blood 
does  not  press  on  the  walls  of  the  vessels,  these  relaxed  and  paralyzed  walls 
cannot  become  filled  and  dilated.2  It  is  still  undecided  whether  the  blood- 
pressure  alone  can  dilate  the  vessels  while  they  retain  their  normal  tone,  i.  <°., 
while  they  are  not  relaxed.  As  far  as  we  have,  until  now,  been  taught  by 
experiment,  this  question  must  be  answered  in  the  negative. 

In  conclusion,  let  me  remark  that  sometimes  the  hyperaemia  is  ascribed  to 
increased  blood-pressure,  even  when  there  is  no  proof  of  this  increase.  So  in 
the  case  of  collateral  hyperaemia.  It  is  true  that  the  occlusion  or  ligature  of 
an  artery  effects  a  dilatation  of  the  bloodvessels  in  the  neighborhood;  but  it 
is  not  demonstrable  that  the  increased  blood-pressure  is  the  cause  of  the  dila- 

1  In  the  dialect  of  the  common  people,  the  phrase  "  Der  Geifer  rirmt  ihm  ana  dem  Munde  vor 
Zorn"  (he  foams  at  the  mouth  M-ith  rage)  is  very  commonly  employed.  The  same  phenomena 
as  those  mentioned  in  the  text  are  presented  in  a  more  marked  degree  in  cases  of  maniacal 
delirium. 

2  I  remind  the  reader  that  an  active  dilatation  of  the  vessels  only  occurs  in  hyperaemia  of  irri- 
tation. 


20  PATHOLOGY    OP    INFLAMMATION. 

tation.  If  we  ligate  the  femoral  artery  of  a  dog,  the  blood-pressure  rises  only 
temporarily.  This  rise  is  a  consequence  of  the  irritation  applied  to  the  nerves 
of  the  artery;  the  irritation  produces  a  reilex  act;  the  rise  of  pressure  is  the 
result  of  reilex  action.  If,  before  the  operation,  we  inject  sufficient  hydrate 
of  chloral  into  the  veins  of  the  animal  to  destroy  the  reflex  excitability,  the 
ligature  of  the  femoral  no  longer  produces  a  rise  of  pressure.  But  the  rise  of 
blood-pressure  after  ligature  of  an  artery  continues  so  short  a  time  that  it  is 
impossible  to  regard  it  as  the  cause  of  the  collateral  hyperemia.  The  im- 
mense dilatation  of  the  vessels  must  accordingly  be  due  to  other  causes;  the 
innervation  of  these  vessels  must  be  altered  to  make  them  dilate  to  such  a 
degree,  and  to  so  thicken  their  walls,  that  capillaries  become  transformed  into 
small  arteries  and  veins.  A  similar,  though  not  so  marked,  an  instance,  is 
the  case  of  venous  reflux.  If  the  blood  from  the  artery  cannot  penetrate  the 
capillaries,  on  account  of  an  obstruction  (e.  g.,  an  embolus),  then  this  capillary 
region  can  become  filled  from  the  direction  of  the  veins,  as  was  first  shown 
by  Virchow,  and  a  hyperemia  can  be  produced  which  is  very  similar  to  the 
hyperemia  of  stagnation.  ISTow  it  is  conceivable  that  we  have  to  deal  here 
with  mechanical  principles  merely.  If  no  blood  enters  from  the  arteries, 
then  the  pressure  in  the  capillaries,  it  is  supposed,  equals  zero,  and  the  least 
pressure  in  the  neighboring  veins  is  sufficient  to  force  the  blood  back  into  the 
capillaries.  But,  after  all  that  we  know  of  the  dilatation  of  vessels,  it  is  not 
probable  that  the  feeble  pressure  which  is  present  in  the  small  veins  is  suffi- 
cient to  dilate  the  capillaries.  If  this  were  possible,  the  capillaries  could  not 
at  all  retain  their  normal  diameter  under  the  variable  influence  of  the  arte- 
rial pressure  to  which  they  are  ordinarily  exposed;  they  would  have  to 
undergo  an  immense  dilatation  under  normal  circumstances.  An  experiment 
performed  on  the  spleen,  by  Bochefontaine,1  is  reported  to  have  shown  that 
the  venous  reflux  (congestion)  is  absent  when  all  nerves  are  pushed  aside 
before  tying  the  splenic  artery;  that  is,  when  only  the  artery,  and  not  also 
the  accompany ing  nerves  are  tied.  In  concluding  this  section,  it  may  not  be 
out  of  place  to  mention  that  simple  hyperemia  of  stagnation  depends  solely 
on  mechanical  causes.  Xevertheless,  we  do  not  know  but  that  the  vaso-motor 
innervation  is  also  changed,  and  that  the  dilatation  of  the  vessels  is  produced 
in  this  way. 


Consequences  of  Hyperemia ;  (Edema  and  Hemorrhage. 

In  order  to  appreciate  the  consequences  of  hyperremia,  we  must  once  more 
consider  the  capillary  walls.  The  contractile  cells  have  a  peculiar  condition 
of  aggregation.  They  are  not  fluid,  but  nevertheless  their  parts  move  among 
each  other  as  though  they  were  fluid.  If  we  watch  a  pigment  granule  in  an 
amoeboid  cell,  we  sec  that  it  changes  its  position  in  the  cell  almost  constantly. 
1  f,  furthermore,  we  watch  with  a  high  power  the  so-called  coarsely-granulated, 
white  blood-corpuscles  of  the  frog,  we  soon  observe  that  the  coarse  granules 
are  not  stationary;  they  alter  their  relative  positions,  and  also  their  shape. 
If  we  accurately  fix  upon  a  granule,  we  see,  in  addition,  that  it  does  not  pre- 
sent a  constant  appearance.  A  granule  may  become  a  fine  thread;  the  thread 
may  disappear  completely;  it  may  perish  in  the  hyaline  basis-substance  of 
the  cell,  in  which  the  grannies  are  apparently  imbedded.  In  other  places 
new  granules  appear.  This  phenomenon  can  he  seen  readily  with  a  No.  15 
lens  of  Ilartnack.     On  the  other  hand,  a  still  more  powerful  lens2  (No.  X  of 

1  Archives  de  Physiologic,  1874,  p.  698. 

2  Claimed  to  correspond  with  No.  -4  Ilartnack. 


CONSEQUENCES    OF    HYPER^IIA.  21 

Seibert  and  Kraft)  permits  me  to  recognize  a  continual  inner  movement  in 
the  white  blood-corpuscles  of  man,  even  if  they  are  externally  at  rest.  Im- 
mediately after  the  specimen  of  blood  is  taken  from  the  linger,  the  white 
globules  look  like  little  lumps;  their  external  contour  does  not  change.  But 
though  the  external  contours  remain  unchanged,  the  new  lens  teaches  me 
that  there  is  a  continual  displacement  of  the  mass  in  the  interior.  On  a 
brighter  background  we  see  an  irregular  dark  picture,  with  contours  which 
are  at  times  clear,  at  times  ill-defined;  and  this  picture  changes  uninterrupt- 
edly. The  whole  makes  an  impression  similar  to  that  of  the  transformation 
of  light  and  shade  in  a  cloud.  I  shall  call  this  motion  an  internal  fairing 
motion.  Only  at  a  later  period  (perhaps  under  the  influence  of  stimuli  to 
which  the  blood-corpuscle  is  exposed  on  the  slide),  does  it  commence  its 
amoeboid  movements,  does  it  change  its  external  form  and  its  position. 

Much  more  striking  are  the  internal  movements  which  the  lens  X  (Seibert 
and  Kraft)  shows  in  the  salivary  corpuscles.  It  was  known  long  ago  that 
granules  which  had  a  swinging  motion  existed  in  the  salivary  corpuscles.  A 
No.  8  lens  of  Hartnack  permits  one  to  see  these  distinctly.  These  movements 
were  called  molecular — because  they  are  similar  to  those  observed  with  high 
powers  in  the  case  of  finely  divided  granules1  suspended  in  water.  The  Xo. 
X  lens  has  taught  me,  however,  that  in  the  salivary  corpuscles  there  are  no 
granules  at  all.  The  salivary  corpuscle  is  traversed  by  a  sharply  defined  net- 
work, which  is  in  continuous,  undulating  motion.  Single  trabecule  of  this 
network  are  seen,  as  though  in  transverse  section,  and  thus  simulate  granules. 
If  we  watch  a  salivary  corpuscle  until  it  bursts,  we  find  that,  the  moment  it 
bursts,  the  undulating  motion  of  the  net  ceases.  But  all  the  salivary  cor- 
puscles do  not  burst ;  in  some,  the  undulation  gradually  becomes  feebler 
without  their  rupturing,  and  just  these  moments  of  enfeeblement  are  suited 
to  demonstrating,  with  the  greatest  precision,  the  existence  of  the  undulating 
net,     I  shall  call  this  motion  the  internal  undulating  motion. 

Experiments  of  Recklinghausen  have  already  made  known  the  fact,  that 
by  the  addition  of  water  to  a  lymph  corpuscle  we  can  produce  a  body  resem- 
bling the  salivary-corpuscle.  The  salivary-corpuscle,  on  the  other  hand,  again 
becomes  an  amoeboid  body,  by  the  addition  of  a  solution  of  salt  from  a  half 
to  one  per  cent,  in  strength.  Now  I  have  lately  discovered  that,  by  the  addi- 
tion of  water2  to  the  white  blood-corpuscles,  an  undulating  net  appears,  just 
like  the  one  present  in  salivary-corpuscles — a  net  whose  undulation  ceases 
with  the  rupture  of  the  corpuscles.  Accordingly,  the  externally  quiescent 
salivary-corpuscle  differs  from  the  externally  quiescent  white  blood-corpuscle 
only  in  the  character  of  the  internal  motion.  One  kind  (the  flowing)  can  be 
converted  into  the  other  (the  undulating).  If  the  white  blood-corpuscle  has 
been  converted  into  a  body  similar  to  a  salivary-corpuscle,  by  means  of  care- 
fully diluting  its  medium  with  water,  then  the  internal  flowing  displacements 
of  the  mass  cease,  and  in  their  stead  we  have  the  undulating  movements.  The 
undulating  net  forms  standing  waves,  as  it  were.  The  network  remains 
constantly,  beams  remain  beams,  meshes  remain  meshes,  even  though  the 
whole  sways  to  and  fro.  If,  on  the  other  hand,  the  salivary-corpuscle  becomes 
an  amoeboid  cell,  then  the  undulating  motion  ceases,  and  the  slow  internal 
flowing  begins.  As  long  as  onty  the  motion  of  these  apparent  granules  was 
known,  the  question  was  discussed,  whether  it  was  a  vital  motion.  On  the 
ground  of  his  electrical  experiments,  Briicke3  argued  in  favor  of  their  vital 

1  Wrongly  called  molecules  by  the  older  biologists. 

2  The  water  must  be  added  very  carefully.  Still  better  than  water  is  a  very  dilute  solution  of 
salt — say  about  yff  per  cent. 

3  Wiener  Sitzungsber.,  18(52. 


22  PATHOLOGY    OF    INFLAMMATION. 

nature,  and  now  there  can  no  longer  be  any  doubt  regarding  the  correctness 
of  this  view. 

We  already  deduce  from  these  observations,  that  the  contractile  bodies  can 
alter  their  physical  condition  very  quickly.  If  now  we  also  remember  that 
contractile  cells  alter  their  consistence  with  increasing  age  ;  if  finally,  I  repeat 
once  more  (reserving  the  proof  until  later),  the  more  resistant  cells  of  older 
animals  return  to  their  youthful  condition  in  the  inflammatory  process,  it 
becomes  comprehensible  with  what  variable  structures  we  have  to  deal  here. ' 
In  the  case  of  the  isolated  cell,  in  the  pus-  lymph-  salivary-corpuscle,  the  rapid 
temporary  change  is  produced  by  influences  in  the  surrounding  medium.  In 
the  cells  of  glands,  similar  changes  are  excited  by  nervous  influence.  As  soon 
as  the  cell  in  the  gland  begins  to  enlarge  under  the  influence  of  either  direct 
or  nervous  stimuli,  its  internal  mass  begins  an  active  flowing  motion.  Ac- 
cordingly, if  we  say  that  the  capillaries  are  contractile,  we  must  not  conclude 
that  they  always  retain  the  same  physical  properties.  We  have  rather  cause 
for  supposing  that  under  the  nervous  influence  not  only  the  thickness  of  the 
wall  and  the  lumen  of  the  tube,  but  also  the  physical  structure  of  the  wall, 
becomes  changed.  The  striped  muscular  fibres,  moreover,  give  us  evident 
proof  of  this.  In  a  condition  of  contraction  the  muscle  is  hard ;  in  a  condi- 
tion of  relaxation  it  is  soft  and  doughy. 

Xow,  inasmuch  as  hyperemia  is  accompanied  in  many  if  not  in  all  instances 
by  a  change  of  innervation,  it  is  clear  that  from  this  standpoint,  already,  an 
alteration  of  the  wall  of  the  vessel  can  arise  in  its  train.  But  alterations  of 
the  walls  of  vessels  are  of  influence  on  the  mutual  relation  of  blood  and 
tissue.  The  capillaries  are  the  main  channel  for  the  nutritive  current,  and 
the  dimensions  of  this  current  certainly  depend,  cccteris  paribus,  on  the  physical 
properties  pf  the  vascular  wall.  But  apart  from  the  innervation,  we  must 
consider  the  influence  of  the  coarser  mechanical  effects  on  the  wall  of  the 
vessel.  During  dilatation,  the  walls  of  the  capillaries  must  become  thinner 
and  better  adapted  to  filtering  than  normally.  Coincidently  with  the  dilata- 
tion of  the  capillaries,  the  blood-pressure  also  doubtless  rises  in  them,1  and  it 
is  self-evident  that  filtration  is  promoted  by  the  increased  pressure.  As  long 
as  the  vessels  are  normal,  these  mechanical  influences  are  perhaps  of  minor 
importance.  But  in  the  case  of  prolonged  hyperemias,  these  prolonged, 
though  slight,  influences  also  gradually  produce  changes  in  the  vascular 
walls. 

Finally,  in  hyperemia,  we  must  consider  the  influence  which  the  changed 
composition  of  the  blood  exerts  on  the  vascular  wall ;  namely,  the  pronounced 
venous  character  of  the  blood  in  hyperemia  of  stagnation  and  in  venous 
reflux,  and,  again,  the  abnormally  arterial  character  of  the  capillary  blood  in 
active  hyperemia.  In  this  respect  it  is  worthy  of  mention  that  hyperemias 
of  stagnation  are  never  or  only  seldom  followed  by  inflammation  (at  least 
not  directly),  but  by  oedema,  hemorrhages,  and  (in  the  case  of  circumscribed 
stasis  especially)  migration.  There  is  no  better  means  of  demonstrating 
migration  than  by  producing  stasis  in  a  small  vascular  district.  If  after  a 
short  time  the  stasis  disappears,  the  wall  of  the  vessel  looks  as  if  strewn  with 
blood-corpuscles,  many  on  the  point  of  passing  through.  Above  and  below, 
to  the  right  and  to  the  left,  they  are  suspended,  and  we  can  easily  observe 
all  phases  of  their  passage.  This  circumstance  also  led  me  to  the  discovery 
of  diapedesis  in  1865.  For  at  that  time  I  covered  the  tails  of  curarized  tad- 
poles with    thin   covering-glass;    and  the  pressure  of  the  covering-glass   is 

1  Only  in  the  capillaries  and  vi'ins,  not  in  the  large  arteries.  Here  the  pressure  can  fall,  for 
example,  from  100  to  00  mm.  mercury,  whilst  in  the  capillaries  it  may  rise  from  10  to  30  mm. 
in'  i  oury. 


CARDINAL    SYMPTOMS    OF    INFLAMMATION.  23 

sufficient  in  the  case  of  tadpoles  to  cause  stasis  and  migration.  In  the  fully- 
developed  frog  this  is  not  produced  so  quickly.  In  the  mesentery  of  that 
animal,  we  must  continue  the  stasis  several  (as  much  as  twenty-four)  hours, 
in  order  to  be  sure  of  obtaining  a  view  of  the  migration  of  corpuscles. 

Active  hyperemia  can  lead  to  oedema  under  special  circumstances,  yet 
well-marked  oedema  does  not  belong  to  the  regular  consequences  of  active 
hyperemia.  More  frequently  metamorphoses  of  tissue  arise  which  must  be 
regarded  as  commencing  inflammation.  True,  we  are  taught  that  simple 
hyperemia  does  not  lead  to  inflammation ;  that  the  appearance  of  inflam- 
mation presupposes  the  existence  of  another  cause  besides  that  of  hyperemia. 
In  fact,  we  must  admit  that  temporary  hyperemias  do  not  produce  any 
marked  alterations  in  normal  tissues.  But  when  the  normal  condition  has 
been  disturbed — -when,  for  example,  an  organ  has  just  passed  through  an 
inflammatory  process — then  moderate  hyperemias,  such  as  accompany  a 
moderate  exercise  of  function,  suffice  to  re-excite  the  inflammation.  This  is 
partly  the  reason  why  physicians  are  inclined  to  keep  at  absolute  rest,  during 
a  considerable  period,  organs  which  have  been  inflamed,  since  a  hyperemia 
accompanies  the  exercise  of  function  in  the  case  of  every  organ  (see  page  19), 
and  hyperemia  favors  relapse.  On  the  other  hand,  it  seems  that  frequent 
and  prolonged  hyperemias  can  very  well  cause  hypertrophies  and  chronic 
inflammatory  tissue-metamorphoses.  I  say  it  seems,  because,  in  all  cases 
where  tissue-changes  arise  (even  if  they  are  only  simple  hypertrophies),  one 
can  say  it  was  no  simple  hyperemia. 


Cardinal  Symptoms  of  Inflammation. 

Since  the  time  of  Celsus,  the  following  have  been  regarded  as  the  cardinal 
symptoms  of  inflammation,  namely :  Heat,  redness,  pain,  and  swelling.  In 
modern  times,  another  sign  has  been  added — that  of  impaired  function.  I 
believe,  however,  that  we  would  do  well  to  discontinue  this  mode  of  charac- 
terizing the  process  and  adopt  another.  Inflammation  is  characterized  by 
two  features :  (1)  by  an  active  hyperemia,  and  (2)  by  an  active  tissue-meta- 
morphosis. I  call  these  changes  active  because  the  tissues  take  part  in  them 
as  living  constituents  of  the  organism  ;  as  living  masses.  If  an  active  hyper- 
emia occurs  alone,  we  can  evidently  not  call  it  inflammation.  If  the  active 
metamorphosis  of  the  tissue  arises  alone,  without  a  trace  of  hyperemia,  we 
again  do  not  speak  of  inflammation,  but  of  a  new  formation. 

Active  hyperemia,  when  situated  in  the  skin  or  in  superficial  mucous 
membranes,  causes  redness  and  increase  of  temperature,  the  latter  having 
evidently  suggested  the  name  "inflammation."  The  older  physicians  did 
not  clearly  understand  that  the  increase  of  temperature  could  be  produced 
by  an  accelerated  circulation,  that  is  to  say,  secondarily.  They  pictured  to 
themselves  that  something  must  be  burning  in  the  part  affected.  Febris 
(from  ferveo)  and  Injiammatio  were  therefore  allied  diseases  for  them. 
Inflammation,  it  was  said,  was  local  fever.  In  the  case  of  fever  it  has  now 
been  ascertained  that  it  is  accompanied  by  an  increased  production  of  heat. 
But  for  inflammation  this  is  not  positively  determined.  It  is  possible,  and 
even  not  altogether  improbable,  that  the  active  tissue-metamorphosis  of 
inflammation  is  accompanied  by  an  abnormal  local  production  of  heat ;  but 
it  is  not  proved.  Accordingly,  all  that  can  be  considered  as  positively 
established  is  that  the  elevation  of  temperature  of  inflamed  regions  of  skin  is  due 
in  great  measure  to  the  hyperemia  ;  to  the  accelerated  blood-current. 

What  I  said  previously  (page  2)  in  regard  to  the  heating  of  the  tissue 
by  the   blood-current  had  reference  only  to  the  external  skin  and  super- 


24  PATHOLOGY    OF   INFLAMMATION. 

ficially  situated  mucous  membranes,  that  is,  to  parts  which  are  in  contact 
with  the  atmosphere,  and,  according  to  the  protection  which  their  position 
offers,  cool  oft'  more  or  less  if  they  are  not  heated  by  the  blood-current. 
Whether  a  more  deeply  situated  organ — the  kidney,  for  example — cools  oft* 
when  little  or  no  blood  flows  into  it,  we  do  not  know ;  for  the  internal 
organs  have  the  temperature  of  the  blood,  and  a  mass  relatively  as  small  as 
the  kidney  could  be  kept  warm  by  its  surroundings  even  if  no  blood  flowed 
into  it.  Hence  it  seems  expedient  to  omit  the  symptom  "heat"  altogether 
from  the  definition  of  inflammation,  and  in  place  of  both  heat  and  redness 
to  put  simply  "  active  hyper&mia"  or  "fluxion." 

The  symptom  pain  is  also  not  always  met  with.  Not  all  organs  are  painful 
when  inflamed,  though  no  doubt  it  seldom  occurs  that  inflammations  run 
their  course  painlessly.  But  we  must  remember  that  in  the  neighborhood  of 
less  sensitive  organs  (parenchyma  of  the  lungs,  for  instance),  there  are  as  a 
rule  very  sensitive  parts,  which  cause  pain  when  they  are  in  the  slightest 
degree  implicated.  Thus  the  pleura,  covering  the  lungs ;  the  meninges,  the 
surface  of  the  brain.  Of  itself,  therefore,  pain  is  not  generally  a  trustworthy 
symptom  of  inflammation. 

The  same  may  be  said  of  the  symptom  swelling.  We  are  not  sure  whether 
the  bones,  for  example,  necessarily  show  an  externally  visible  swelling  in 
inflammation.  I  must  remark  right  here  that  inflammatory  swelling  is  dis- 
tinguished by  its  hardness,  and  in  many  cases  the  hardness,  not  the  visible 
swelling,  is  the  decisive  characteristic.  If  I  see  a  reddened  district  in  the 
skin ;  if  I  palpate,  and  find  it  hot  and  hard  ;  I  say  it  is  inflamed,  even  though 
no  swelling  be  visible.  And  it  is,  indeed,  possible,  that  the  swelling  at  times 
may  become  unrecognizable,  as  for  example  when  the  inflammation  is  seated 
in  a  nodular,  uneven  neoplasm.  The  inflammatory  swelling  and  hardness  are, 
as  I  shall  show,  dependent  on  the  active  tissue-metamorphosis.  I  say,  there- 
fore, that  the  tissue-metamorphosis  is  a  generally  reliable  symptom,  and  put 
it  in  the  place  of  swelling. 

The  active  tissue-metamorphosis  likewise  includes  the  symptom  impaired 
function,  for  I  shall  show  that  the  tissues  when  undergoing  inflammatory 
changes  have  their  function  impaired.  But  this  change  is  a  gradual  one.  A 
muscle  can  still  contract  at  the  commencement  of  inflammation,  when  the 
tissue-metamorphosis  has  already  begun,  and  can  be  recognized  under  the 
microscope. 


General  Eemarks  concerning  the  Inflammatory  Changes  of  Tissues. 

The  inflammatory  changes  of  tissues  may  be  described  in  a  few  words.  As 
soon  as  an  inflammation  occurs,  the  tissues  return  to  their  embryonic  state. 
In  the  embryo,  the  entire  organ  consists  of  amoeboid  cells.  The  inflamed 
tissue  of  older  animals,  which  is  normally  composed  of  more  rigid  cells  and 
intermediate  substance,  is  again  converted  into  amoeboid  cells,  or,  I  should 
prefer  to  say,  into  amoeboid  substance,  in  view  of  my  most  recent  researches. 
The  subdivided  amoeboid  substance,  or  the  amoeboid  cells  of  an  inflammatory 
focus,  are  called  pus-eorpuscles.  It  is  accordingly  the  tissue  itself  which  is 
transformed  into  pus-corpuscles. 

Although  I  am  writing  here  in  the  interest  of  practical  branches,  I  cannot 
desist  from  advancing  the  reasons  for  this  theory.  I  must  show  its  relation 
to  older  theories,  and  what  reasons  have  influenced  me  in  discarding  the  older 
theories  and  especially  the  migration  theory.  But  this  explanation  is  only 
possible  if  I  give  the  reader  a  sketch  of  general  histology.  If  we  desire  to 
become  acquainted  with  the  processes  which  occur  in  an}- apparatus  (Einrich- 


THEORY    OF   INFLAMMATION.  25 

tung)  we  must  possess  information  regarding  the  apparatus  itself.  This 
sketch  of  general  histology  will  likewise  be  in  place  here,  inasmuch  as  it  will 
also  include  the  doctrine  of  growth  and  nutrition  of  the  tissues,  as  well  as 
the  doctrine  of  regeneration  and  cicatrization. 


Historical  Remarks  concerning  the  Theory  of  Inflammation. 

From  about  1855  down  to  1867,  Virchow's  theory  of  inflammation,  the 
so-called  suppuration-theory,  was  almost  universally  accepted.  The  pus- 
corpuscles  were  said  to  be  formed  from  the  connective-tissue  cells.  At  first 
the  nuclei  of  the  cells,  and  then  the  cells  themselves,  were  supposed  to  sub- 
divide, and  by  means  of  these  subdivisions  the  pus-corpuscles  were  believed 
to  be  produced.  In  the  year  1867,  Cohnheim1  contradicted  this  theory.  The 
pus-corpuscles,  he  said,  are  migrated  white  blood-corpuscles.  This  assertion 
was  partly  based  on  a  study  of  the  inflamed  cornea,  stained  with  gold.  In 
spite  of  the  fact  that  the  inflamed  cornea  appeared  tilled  with  pus-corpuscles, 
the  cornea-corpuscles  were,  as  he  asserted,  entirely  unaltered.  The  source  of 
the  pus-corpuscles  had,  therefore,  to  be  sought  elsewhere  than  in  the  cornea- 
corpuscles.  The  branched  cornea-corpuscles,  Cohnheim  said,  are  fixed  cells  ; 
they  change  neither  their  locality  nor  their  form.  The  pus-corpuscles,  on  the 
other  hand,  are  amoeboid  ;  they  change  their  position  and  their  form.  It  was 
known,  long  before  this,  that  the  pus-corpuscles  were  similar  to  the  white 
blood-corpuscles,  and  that  the  white  blood-globules  were  amoeboid,  and  it  was 
therefore  natural  to  consider  them  identical.  In  addition,  Recklinghausen 
now  made  the  discovery  that  amoeboid  cells  could  migrate  into  the  lifeless 
cornea,  and  wander  about  in  its  tissue. 

Xow,  stimulated  by  my  discovery  of  the  diapedesis  of  red  blood-corpuscles, 
Cohnheim  and  Hering  (independently  of  each  other)  came  to  the  conclusion 
that  white  blood-corpuscles  could  also  migrate.  Cohnheim  observed  the 
migration  in  the  mesentery  of  the  frog,  after  exposure  to  the  air.  The  influ- 
ence of  the  air  could  be  regarded  as  an  irritation  capable  of  producing  inflam- 
mation. In  such  cases  the  mesentery  soon  became  covered  with  amoeboid 
cells.  Accordingly,  we  had  before  us  inflammatory  products,  pus-cells ;  one 
was  therefore  apparently  justified  in  saying,  "Here  is  inflammation;  and  the 
products  of  inflammation,  the  pus-corpuscles,  originate  from  the  blood." 
Whether  the  changes  in  the  expanded  mesentery  were  really  to  be  regarded 
as  inflammation  and  suppuration,  or  not,  was  indeed  not  known.  First  of  all, 
the  most  important  sign,  the  inflammatory  hardness,  was  missing.  Moreover, 
nobody  had  observed  a  destruction  of  the  tissue,  by  suppuration,  in  the  spread 
out  mesentery.  Finally,  only  a  migration  out  of  the  vessels  of  the  mesentery 
was  known.  Whether  in  the  case  of  keratitis  wandering  cells  really  passed 
into  the  cornea,  was  not  known.  But  the  boldness  with  which  Cohnheim 
positively  affirmed  that  the  cloudiness  and  suppuration  always  began  on  the 
borders  of  the  cornea,  even  if  it  was  injured  in  the  centre,  gave  his  theory  a 
substantial  support;  for  such  an  observation  would  speak  directly  in  favor  of 
the  fact  of  the  pus-corpuscles  penetrating  the  cornea  from  without  (from  the 
periphery). 

Then  came  the  experiment  of  the  so-called  "  feeding  of  the  cells."  If  we 
introduce  finely  divided  coloring  matter  (cinnabar,  aniline)  into  the  circula- 
tion of  the  frog,  the  granules  of  pigment  are  absorbed  by  the  white  blood- 
corpuscles  within  the  general  circulation.  If  we  now  examine  a  drop  of 
blood,  we  shall  see  amoeboid  cells  containing  granules  of  pigment.     If  we 

1  Virchow's  Arcliiv,  Bd.  40. 


26  PATHOLOGY    OF    INFLAMMATION. 

excite  a  keratitis  after  the  injection  of  the  coloring  matter,  and  cut  out  the 
cornea  when  the  inflammatory  process  is  at  its  height,  we  shall  also  see, 
in  occasional  instances,  similar  amoeboid  bodies  which  contain  pigment 
granules. 

]STow  if  the  cornea-corpuscles  do  not  become  changed  in  inflammation,  and 
do  not  generate  pus-corpuscles;  if  the  pus-corpuscles  always  penetrate  the 
cornea  from  the  border,  where  the  bloodvessels  are  situated ;  if  the  pus-cor- 
puscles are  similar  to  the  white  blood-corpuscles;  if  the  white  blood-corpu.s- 
cles  really  migrate,  who  would  doubt  any  more  that  the  pus-corpuscles  origi- 
nated from  the  blood?  However,  in  the  year  1869,1  I  had  already  found  out, 
in  conjunction  with  W.  F.  Morris,  that  Cohnheim  had  examined  the  cornea 
imperfectly ;  that  the  cornea-corpuscles  in  fact  did  change ;  that  their  nuclei 
increased ;  that  they  became  amoeboid  in  the  course  of  the  inflammatory  pro- 
cess. True,  we  said,  they  do  not  all  change  at  once;  they  do  not  change 
everywhere  in  the  entire  cornea,  but  only  where  a  centre  of  suppuration  is 
forming.  But  in  the  rest  of  the  cornea  wre  see  the  old  cornea-corpuscles  at 
the  side  of  single  new  cells  which  look  like  pus-corpuscles.  But  inasmuch  as 
at  that  period  we  likewise  could  not  observe  movements  in  the  branched 
cornea-corpuscles  (in  their  normal  condition);2  and  inasmuch  as  we  had 
learned  that  they  became  amoeboid  (like  white  blood-corpuscles)  during  in- 
flammation, we  said  that  the  newly-formed  corpuscles  had  passed  into  this 
neighborhood,  and  had  become  visible  beside  the  unchanged  branched  cornea- 
corpuscles.  Norris  and  I  have  furthermore  showTn  that  the  suppuration  does 
not  always  begin  at  the  edge  of  the  cornea,  as  Cohnheim  asserted,  but  that  it 
begins  where  t/ie  invitation  has  exerted  its  influence. 

Finally,  wre  have  shown  that  the  experiment  with  the  pigment  is  no  argu- 
ment in  favor  of  the  migration  theory.  After  the  injection  of  coloring 
matter  into  the  blood,  pigment-granules  can  also  be  found  in  the  branched 
(supposed  fixed)  cells.  Therefore,  the  presence  of  pigment-granules  in  the 
amoeboid  cells  of  the  cornea  cannot  be  regarded  as  a  sign  of  their  originating 
from  the  blood.  Even  a  single  consideration  teaches  us  how  deceptive  this 
sign  is.  In  consequence  of  the  inflammatory  hyperaemia,  an  increased  nutri- 
tive current  flows  into  the  focus  of  inflammation.  The  vascular  wall  is,  as 
we  know,  permeable ;  red  and  white  blood-corpuscles  can  pass  through  it; 
why  should  not  the  much  smaller  pigment-granules  likewise  be  carried 
through  the  wrall  of  the  vessel  and  into  the  cornea,  by  the  nutritive  current? 
Once  arrived  in  the  cornea,  they  can  adhere  to  the  soft  and  sticky  pus-cor- 
puscles, and  reach  their  interior. 

Of  the  arguments  in  favor  of  the  migration  theory  there  only  remained  the 
fundamental  fact,  that  the  blood-corpuscles  in  general  could  migrate.  But, 
as  already  remarked,  nobody  has  proved  that  they  migrate  in  the  course  of  a 
keratitis,  or  that  they  pass  into  the  cornea.  Properly  speaking,  the  state  of 
the  question  was  now  as  follows:  It  was  certain  that  the  pus-corpuscles  in  the 
cornea  were  produced  from  pre-existing  elements.  It  was  uncertain  whether, 
in  addition,  pus-corpuscles  penetrated  it  from  without.  I  and  several  of  my 
pupils  had  likewise  observed  the  genesis  of  pus-corpuscles  from  the  cells  in 
other  li-siics,  and  thus,  in  1809,  I  could  already  say  that  I  knew  of  no  tissue 
in  which  the  inflammation  and  suppuration  were  to  be  referred  solely  to 
migration. 

out  :it  that  time  I  laid  the  greatest  weight  upon  the  alterations  of  the 
capillaries.     In  the  case  of  all  other  tissues,  one  might  object  (and  the  objection 

1  Stmli.-n  ana  dem  Inst.  f.  exp.  Path.     Wien,  1SH0. 

2  New  researches,  of  which  I  shall  speak  hereafter,  demonstrate  that  these  hodies,  too,  are 
in'   .  able. 


THEORY    OF    INFLAMMATION.  27 

has  been  raised)  that  I  was  deceived,  that  I  did  not  prepare  the  specimens 
properly.  Those  parts  of  the  inflammatory  focus,  it  was  argued,  which 
exhibited  no  normal  cornea-corpuscles  at  all,  I  had  stained  imperfectly. 
Where  I  supposed  that  I  had  seen  corpuscles  which  had  been  changed  by  the 
inflammation,  it  was  said  that  I  had  been  dealing  with  lifeless,  and  therefore 
changed,  cornea-corpuscles.  Where  I  asserted  that  I  had  seen  multi-nucleated 
amoeboid  corpuscles,  produced  from  the  cornea-corpuscles,  it  was  argued  that 
I  had  been  deceived  by  white  blood-corpuscles  which  had  coalesced.  If  I 
spoke  of  an  increase  of  nuclei,  they  were  explained  as  the  lifeless,  broken- 
down  nuclei  of  the  old  cells.-  The  thickening  of  the  capillaries,  however; 
the  sending  out  of  new  processes;  the  numerous  nuclei  which  were  scattered 
about  in  their  walls;  these  were  all  reliable  indications  that  inflammation  was 
accompanied  by  an  active  tissue-metamorphosis.  JSTew  bloodvessels  and  off- 
shoots of  the  same  cannot  migrate. 

But,  in  the  mean  time,  the  migration  theory  had  been  too  favorably  re- 
ceived to  permit  of  influencing  its  believers  with  arguments.  And  this  great 
favor  was  due,  in  part,  to  its  simplicity.  It  was  convenient  for  the  clinical 
teacher  and  pathological  anatomist  to  be  able  to  enunciate  the  foundation  of 
all  pathological  histology  in  a  single  sentence.  They  might  say  to  them- 
selves that  histology  was  really  superfluous  for  them.  If  they  only  knew  that 
the  white  blood-globules  migrated,  penetrated  the  tissues,  and  appeared  there 
as  pus-corpuscles,  they  thought  that  with  these  few  propositions  they  had 
acquired  all  that  was  of  real  importance. 

On  the  other  hand,  the  doctrine  of  the  tissue-metamorphosis,  as  I  shall  call 
my  theory,  was  at  that  time  (in  the  year  18G9)  still  in  a  sorry  plight.  I  and 
my  pupils  had  seen  only  a  rudimentary  portion  of  the  metamorphosis.  In 
principle,  we  had  scarcely  proceeded  farther  than  Virchow's  doctrine;  for  we 
did  not  advance  more  than  the  fact,  which  had  been  denied  by  Cohnheim, 
that  nuclei  and  cells  did  divide.  Only  as  regards  the  mode  of  division  did  I 
bring  forward  a  new  explanation,  which  corresponded  to  the  state  of  the  cell- 
doctrine  of  that  time.  I  showed,  namely,  that  the  cell-division  did  not  pro- 
ceed as  taught  in  Virchow's  theory.  For  this  theory  taught,  that  at  first  the 
nucleus  divided  into  two  portions ;  that  the  nuclei  moved  apart ;  that  the  cell 
then  became  biscuit-shaped;  that  the  heads  of  the  biscuit  contained  the  new 
nuclei,  and  then  separated.  I  showed,  however,  that  the  cells  became  amoe- 
boid before  division.  While  the  cells  of  the  completed  tissue,  in  consequence 
of  the  methods  of  examination  of  that  period,  appeared  to  remain  in  the  tissue 
unaltered;  in  the  commencement  of  inflammation,  I  said,  they  again  begin 
their  independent  movements.  I  said,  again  begin,  since  in  the  embryo  this 
capability  of  motion  is  possessed  by  all  cells.  Therefore  I  likewise  said,  that 
the  cells  return  to  their  embryonic  state.  I  showed,  furthermore,  that  before 
division  the  cells  were  doubled  up  into  a  small  mass,  remained  quiet  in  this 
condition  for  a  time,  and  then  divided  by  cleavage.  As  soon  as  the  cleavage 
was  over,  the  fragments  crept  asunder.1  I  showed,  moreover,  that  there  was 
still  another  kind  of  division.  I  had  seen  cells  which  were  torn  into  two 
pieces  during  their  uninterrupted  movements. 

These  observations  indeed  taught  us  how  pus-corpuscles  were  formed  out 
of  connective-tissue  corpuscles,  but  they  opened  up  the  disagreeable  prospect 
that  we  might  be  compelled  to  examine  every  tissue  separately  in  order  to 
ascertain  if  and  how  the  formation  of  pus  proceeded  in  each  various  type. 
But,  moreover,  the  theory  of  metamorphosis  was  just  as  little  suited  to 
explaining  the  macroscopical  (clinical)  phenomena  as  the  migration-theory. 
At  the  bedside  we  do  not  see  any  pus-corpuscles  with  the  naked  eye.     We 

1  Strieker's  Studien,  etc. 


28  PATHOLOGY   OF   INFLAMMATION. 

see  redness  and  feel  hardness ;  we  learn  that  the  hard  spots  in  the  centre 
soften  (resolve  or  melt,  as  the  old  physicians  called  it).  These  phenomena 
were  left  unexplained  hy  the  one  theory  as  well  as  by  the  other. 

But  the  condition  of  affairs  has  now  changed.  In  the  year  1874,  I  began 
to  study  keratitis  in  mammalia,  and  here  obtained  results  which  explained 
the  clinical  phenomena  satisfactorily.  Starting  from  this  point,  I  examined 
all  kinds  of  tissue,  and  the  results  obtained  were  of  such  a  nature  that  I  also 
can  now  clothe  the  doctrine  of  inflammation  in  a  simple  form.  Metamorphosis 
of  /issue;  return  to  the  embryonic  condition ;  division  into  amoeboid  cells  of  the 
masses  which  have  become  movable ;  hence  the  destruction  and  the  suppuration; 
this  is  briefly  the  outline  of  my  new  doctrine.  On  the  other  hand,  all  the 
details  of  my  further  ^  researches  were  very  favorable  for  my  theory.  It 
appeared  that  this  theory  was  in  harmony  with  the  results  of  researches  in 
the  domain  of  comparative  histology  and  histogenesis.  It  appeared  that  in 
the  pathological  destruction  of  tissue  by  suppuration,  not  only  the  cells,  but 
also  the  entire  tissue,  returned  to  the  embryonic  condition.  The  machine 
was,  as  it  were,  separated  into  its  parts  again.  In  regard  to  the  pathological 
tissue,  therefore,  I  was  about  in  the  position  of  the  mechanic,  who  takes 
apart  the  machine  and  finds  that  which  its  builders  have  asserted  to  be 
present.  It  appeared,  furthermore,  that  the  return  of  the  tissue  to  the 
embryonic  state  at  the  same  time  included  the  conditions  recpuisite  for  a 
healing  of  the  tissue.  In  every  phase  of  the  inflammation  the  destruction 
can  cease,  and  a  regeneration  or  a  cicatrization  can  be  started.  And  this 
new  formation  is  throughout  similar  to  the  embryonic  new  formation.  In 
consequence  of  such  observations,  my  conviction  of  the  correctness  of  my 
theory  of  inflammation  has  been  so  much  strengthened  that  I  believe  that  I 
may  now  venture  to  publish  it  together  with  all  its  deductions.  But  I  must 
finally  remark  that  the  opposition  to  this  theory  has  only  been  heard  in 
modest  tones  during  the  past  few  years.  The  migration-theory  has  proved 
to  be  fruitless.  It  has  made  no  progress  since  1867,  and,  in  regard  to  the 
doctrine  of  inflammation,  it  cannot  make  any  progress;  for  it  denies  the 
active  processes.  But  the  doctrine  of  tissue-metamorphosis  has  made  con- 
stant advances,  and  every  new  step  which  I  have  taken  in  the  course  of  the 
last  decade  has  proved  to  be  an  argument  against  the  migration-theory. 


Suppurative  Keratitis. 

I  have  obtained  a  better  insight  into  the  processes  in  the  cornea  by  a 
method  which  has  turned  out  to  be  very  rich  in  results.  At  first,  I  apply 
an  inflammatory  stimulus  to  the  centre  of  the  cornea  of  a  young  cat  by 
cauterizing  with  caustic  potassa,  or  by  the  introduction  of  a  foreign  body — 
the  most  suitable  being  a  thread  which  is  passed  through  the  centre  of  the 
cornea  and  the  bull)  with  the  aid  of  a  needle,  and  is  then  tied  into  a  knot  for 
the  sake  of  fixing  it.  When  the  inflammation  has  reached  a  certain  height, 
thai  is,  after  about  twenty-four  hours,1 1  narcotize  the  animal  and  paint  the 
cornea  with  lunar  caustic  until  it  becomes  very  turbid  throughout.  Now 
the  animal  is  killed  ;  the  cornea  is  cut  out  and  preserved  in  water  slightly 
acidulated  with  acetic  acid.  On  the  following  day  I  remove  the  cornea  from 
the  acidulated  water  and  split  it  into  lamellae.  This  procedure  is  very  easily 
accomplished  in  the  case  of  cornea;  thus  treated.     By  the  influence  of  the 

1  Such  experiments  are  most,  snreessful  in  spring.  In  the  beginning  of  winter,  the  results 
are,  as  a  rule,  very  ha/1.  In  our  climate  (Vienna),  I  would  recommend  the  months  from  April 
to  October  for  such  experiments. 


SUPPURATIVE   KERATITIS. 


29 


acid,  the  tissue  becomes  swollen,  and  its  parts  are  loosened.  On  the  other 
hand,  from  the  action  of  the  silver  (perhaps  coagulation),  it  has  acquired  a 
certain  hardness.  Consequently  we  can  easily  separate  it  into  lamellae  which 
still  possess  a  certain  hardness.  The  first  cleavage  into  two  lamellae,  and 
then  of  each  of  these  into  two,  I  can  accomplish  with  the  naked  eye.  The 
further  cleavage  I  perform  with  the  aid  of  a  magnifying  glass ;  the  method 
cannot  be  well  described,  but  can  easily  be  found  out  for  himself  by  the 
pra  ctised  manipulator. 

Even  in  the  lamellae  which  have  been  stripped  off  with  the  naked  eye,  we 
can  distinctly  recognize,  under  the  magnifying  glass  (with  transmitted  light;, 
the  inflammatory  focus  and  the  purulent  spot  respectively.  On  these  foci  or 
spots  I  concentrate  my  main  attention  during  the  subsequent  cleavage.  For 
little  is  to  be  gained  by  a  fine  cleavage  of  the  normal  or  slightly  altered  spots 
in  the  neighborhood  of  the  focus.  We  can  obtain  a  view  of  the  normal 
appearance  even  in  thicker,  less  transparent  lamellae.  But  in  the  inflam- 
matory focus  we  do  not  get  clear  and  convincing  pictures  until  we  have  thin 
lamella?.  The  inflammatory  foci  are  less  translucent  than  the  normal  spots ; 
furthermore,  the  accumulation  of  cells  into  heaps  interferes  with  the  exami- 
nation. All  of  these  impediments  are  done  away  with  if  the  lamellae  are 
very  thin.  The  pictures  here  become  so  clear  that  there  can  no  longer  be 
any  doubt  with  regard  to  the  nature  of  the  suppurative  process,  before 
describing  these  pictures,  however,  I  must  correct  an  error  which  has  crept 
in  as  a  consequence  of  the  method  of  staining  with  silver. 

If  we  stain  an  excised  cornea  in  a  solution  of  nitrate  of  silver,  the  branched  cells  of 
the  cornea  appear  as  light  cells  on  a  dark  background.  For  the  basis-substance  of  the 
cornea  in  which  the  cells  lie  imbedded  absorbs  the  silver  better  than  the  cells  do,  and 
accordingly  becomes  stained  a  deep  brown  when  exposed  to  daylight,  while  the  cells 
remain  of  a  light  color.  In  fact,  the  cells  are,  as  a  rule,  not  visible  at  all ;  we  only 
see  light  branched  spots 
(spaces)  on  a  dark  ground. 
(Fig.  6.)  Recklinghausen, 
who  was  the  first  one  to  em- 
ploy this  silver-staining  me- 
thodically, believed  that  the 
cornea  contained  real  spaces, 
and  called  these  spaces  nutri- 
tive canals  (saftkanalchen). 
In  these  spaces  he  thought 
that  the  cells  were  situated, 
and  that  the  amoeboid  cells 
wandered  through  them.  At 
a  later  period,  Cohnheim 
stained  the  cornea  with  chlo- 
ride of  gold,  and  then  a  dif- 
ferent picture  was  presented. 
Anastomosing  figures  were 
also  to  be  seen  here ;  but 
these  figures  proved  to  be 
nucleated  cells  which  had 
been  stained  of  a  violet  color  by  the  solution  of  gold,  and,  in  fact,  more  deeply  stained 
than  the  surrounding  basis-substance.  Accordingly,  the  branched  figures  were  here 
dark  on  a  light  background,  but  in  the  cornea  treated  with  silver,  on  the  contrary, 
light  on  a  dark  background.  Using  the  language  of  the  photographers,  wre  may  say 
that  the  branched  cells  appear  as  positives  after  staining  with  gold,  but  as  negatives, 
on  the  contrary,  after  staining  with  silver. 

This  agreement  of  the  forms,  after  staining  with  silver  and  with  gold,  induced  me  to 


Fisr.  6. 


C.  C.  Cornea  corpuscles. 


30  PATHOLOGY    OF    INFLAMMATION. 

restrict  Recklinghausen's  hypothesis  concerning  the  existence  of  nutritive  canals.1 
There  must  be  spaces  in  the  basis-substance,  I  said,  because  the  cells  must  liave  space 
to  lie  in  ;  but  the  spaces  are  filled  up;  the  cells  are  everywhere  in  intimate  contact 
with  the  basis-substance.  By  means  of  the  silver-staining,  the  cells  become  invisible, 
and  the  light  spaces  then  seem  empty  in  the  dark  basis-substance.  The  silver-staining 
as  I  perform  it — namely,  in  the  living  animal — likewise  colors  the  basis-substance 
darker  than  the  cells ;  but  the  cells,  too,  are  stained,  and  appear  like  nucleated,  granu- 
lated, branched  bodies,  exactly  of  the  shape  of  those  supposed  spaces  which  can  be 
seen  after  staining  with  silver  in  the  case  of  the  excised  cornea,  and  exactly  of  the 
shape  of  those  violet  cells  which  appear  in  specimens  stained  with  gold.  On  the 
ground  of  these  observations,  I  said  that  they  were  not  empty  spaces  (filled  only  with 
fluid),  through  which  the  nutritive  current  passed.  These  spaces  are  filled  up  with 
cells.  Moreover,  an  observation  which  I  had  made  at  an  earlier  period  (18G9,  in  con- 
junction with  Norris)  had,  in  fact,  taught  that  in  the  inflamed  cornea  the  nutritive  cur- 
rents circulated  through  the  cells.  I  have  already  mentioned  under  what  conditions 
we  have  seen  pigment-granules  in  the  branched  cells.  Now,  in  the  case  of  the  excised 
cornea,  these  pigment-granules,  while  under  examination,  passed  through  a  process  of 
one, cell  into  an  anastomosing  process  of  another.  But  the  pigment-granules  can  only 
be  carried  off  passively  by  a  current  of  fluid  (nutritive  current).  Accordingly,  I  said, 
the  nutritive  current  passes  through  the  cells,  and  only  indirectly  through  the  spaces, 
inasmuch  as  the  cells  lie  in  these  spaces. 

These  cells  had  appeared  branched  in  all  species  of  animals  which  I  had  examined 
up  to  that  time.  The  processes  of  the  various  cells,  I  therefore  said,  anastomose  ;  cells 
and  processes  form  a  unit — a  network  ;  the  junctions  of  the  network  possess  nuclei, 
and  are  regarded  as  cells.  These  junctions,  I  added,  are  not  equally  developed  in  all 
species  of  animals.  In  the  frog  and  in  the  rabbit  they  are  very  marked.  Here  we  in 
reality  see  cells  and  processes  as  described  by  authors.  In  certain  fish  which  I  have 
examined,  I  found  only  a  network  of  finely  granulated  substance,  whilst  larger  masses, 
which  might  be  regarded  as  cells,  were  altogether  wanting.  In  the  cat  and  in  the  dog 
the  facts  are  not  the  same  as  in  the  frog.  Here  there  is  likewise  a  more  homogeneous 
network  present,2  only  the  trabecular  of  the  network  are  much  broader  than  in  fishes. 
Accordingly  the  reticular  structure  is  what  appears  to  be  common  to  all  species  of 
animals.  But  all  of  these  observations  were  made  on  lifeless,  stained  cornea?  (with  the 
exception  of  the  cornea  of  the  frog).  Only  in  the  lifeless  cornese  of  the  fish,  the  cat, 
and  the  rabbit,  have  I  seen  this  network.  What  the  appearances  are  in  the  living 
animal  will  be  treated  of  on  a  subsequent  page.  For  the  present,  I  again  lay  stress 
upon  the  fact  that  wre  cannot  recognize  any  structure  in  the  normal  cornea  of  the  frog ; 
freshly  prepared  in  aqueous  humor,  it  appears  light-colored,  glassy,  and  homogeneous. 
Only  in  the  case  of  the  diseased,  turbid,  and  freshly  prepared  cornea  of  the  frog  do  we 
also  see  such  branched  cells  as  can  be  made  to  appear  by  staining  with  silver  or  gold. 

Let  us  therefore  consider  now  only  those  cornese  in  which  we  can  see  the 
network  and  basis-substance  on  account  of  their  different  color  or  differ- 
ent shading.  The  meshes  of  this  network  are  tilled  with  basis-substance. 
This  basis-substance,  as  I  have  already  remarked,  and  as  I  shall  again 
emphasize  here,  is  also  living  matter  (during  the  life  of  the  animal).  For 
the  oiiire  cornea  is  a  living  organ,  the  basis-substance  being  of  a  different 
character  from  that  of  the  cells.  These  two  constituents, react  differently 
during  life3  to  solutions  of  silver  and  of  gold,  and  to  various  other  solutions. 
Therefore  we  believe  that  we  can  distinguish  them  by  staining  with  silver  or 
with  gold.  The  cells  as  well  as  the  basis-substance,  I  say,  are  living  matter,  and 
;tt  times  they  vary  their  relative  positions  (as  is  proved  by  the  stained  speci- 

1  See  my  Vorlesmigen  iilicr  allg.  and  exp.  Path.     Wien,  1878,  S.  280. 

2  Nevertheless  there  are  trabeculseof  varying  thickness  present.  But  pronounced  expansions 
(points  of  junction)  as  they  exist  in  the  cornea  Of  Ho'  frog  arc  for  the  most  part  wanting. 

3  In  the  lifeless  cornea,  the  staining  with  silver  and  gold  prove  to  be  very  imperfect.  There- 
fore nobody  lias  yet,  to  my  knowledge,  succeeded  in  obtaining  such  distinct  pictures  of  the  cornea 
of  man,  as  of  the  cornea  of  animals  which  can  be  stained  while  fresh  or  living. 


SUPPURATIVE   KERATITIS.  31 

mens).  At  one  time  the  basis-substance  becomes  enlarged,  while  the  cells  and 
their  processes  (i.  e.,  the  trabecular  of  the  network)  become  diminished ;  at 
another  time  the  reverse  is  the  case.  Border  quarrels,  as  it  were,  take  place 
between  the  network  of  cells  and  the  basis-substance.  One  and  the  same 
strip  of  territory  is  at  one  period  a  portion  of  the  body  of  a  cell,  or  of  a  pro- 
cess;  at  another  period,  a  part  of  the  basis-substance.  Here  and  there,  also, 
entire  cells  perish,  and  are  completely  converted  into  basis-substance.  As  I 
shall  soon  show,  it  only  requires  changes  of  short  duration  to  transform  the 
basis-substance  into  a  cell,  and,  vice  versa,  a  cell  into  basis-substance.  These 
changes  correspond  on  the  one  hand  to  the  normal  development  of  tissue,  and 
on  the  other  hand  to  pathological  processes. 

In  general,  we  may  say  that  the  larger  cells,  and  also  a  greater  abundance 
of  cells,  are  characteristic  of  a  more  youthful  condition  of  the  tissue.  In  the 
embryo,  we  see  scarcely  anything  but  cells,  separated  by  narrow  traces  of 
intermediate  or  basis-substance.  The  older  the  tissue  becomes,  the  broader 
are  the  traces  of  intermediate  substance,  and  the  more  slender  are  the  cells 
and  their  processes.  The  reverse  takes  place  in  intiammation.  The  more 
advanced  is  the  process  of  inflammation,  the  larger  do  the  bodies  of  the  cells 
and  their  processes  become,  and  the  smaller  are  the  islands  of  basis-substance 
which  till  up  the  meshes  of  the  network. 

But  it  is  now  appropriate  to  describe  more  accurately  these  processes  as 
they  occur  in  intiammation.  I  proceed,  accordingly,  to  the  consideration  of 
those  microscopical  observations,  of  which  it  has  already  been  said  that  they 
are  in  harmony  with  the  clinical  phenomena — observations,  namely,  which 
I  have  made  on  the  inflamed  cornese  of  young  cats,  examined  after  staining 
during  the  life  of  the  animal. 

I  shall  suppose  that  the  inflammation  has  been  excited  by  touching  the 
centre  of  the  cornea  with  caustic  potassa.1  If  now  we  place  under  the  micro- 
scope a  lamella  prepared  according  to  the  specified  method,  we  easily  recognize 
the  cauterized  focus.  Here  no  pus-corpuscle,  not  any  trace  of  an  inflammatory 
process,  is  to  be  found.  The  cornea-corpuscles  and  the  network  respectively 
are  still  to  be  recognized ;  they  present  themselves  as  crumbled  masses. 
Nowhere  a  multiplication  of  nuclei ;  nowhere  an  indication  that  there  was 
still  life  in  them  at  the  time  they  were  stained  with  silver,  that  is,  at  the 
height  of  the  inflammatory  process.  It  is  different  in  the  neighborhood  of 
the  slough.  Here  the  network  of  cornea-corpuscles  appears  greatly  swollen,2 
and  the  basis-substance  in  the  meshes  of  the  network  diminished.  Here  and 
there  the  basis-substance  has  entirely  disappeared,  and  the  network  has  thereby 
become  very  much  nodulated.  The  relation  is  about  the  same  as  if  I  should 
pour  water  on  the  polished  surface  of  a  table,  and  then  spread  it  out  with  the 
finger  into  a  network  over  the  entire  surface.  The  beams  of  the  watery 
network  are  to  represent  the  network  of  cells,  the  dry  islands  of  the  table 
the  basis-substance.  If  now  I  pour  on  water  repeatedly,  the  lines  of  water 
become  continually  increased  in  size,  whilst  the  dry  islands  become  smaller, 
until  finally  nearly  the  entire  table  is  covered  with  great  masses  of  water, 
with  only  here  and  there  a  dry  island  still  visible. 

If  we  look  at  the  lamella  with  a  magnifying  glass  while  it  floats  about  in 
water,  we  notice  that  in  all  those  places  where  the  network  of  cells  is  swollen, 
the  lamella  is  swollen  too.  If  we  expose  such  a  lamella  to  diffused  daylight 
for  some  hours  (even  up  to  several  days),  we  shall  soon  recognize  with  a  power 

1  Best  as  follows  :  Melt  caustic  potassa  in  a  silver  crucible,  and  allow  it  to  be  sucked  up  by 
capillary  attraction  into  very  fine  glass  tubes.  Eacb  of  tbese  tubes  maybe  employed  to  cauterize 
repeatedly,  by  breaking  off  the  used-up  point. 

2  Always  in  patches  only  ;  I  have  never  seen  this  change  in  the  entire  circumference  of  the 
eschar. 


82  PATHOLOGY    OF    INFLAMMATION. 

of  200  or  300  diameters  a  new  picture  in  the  swollen  network  of  cells.  We 
see,  namely,  that  the  network  of  cells  in  the  thickened  region  is  divided  into 
small  fields  by  brown  lines.  In  each  of  these  spaces,  moreover,  we  find  either 
one  or  several  small  nuclei.  Sometimes  these  nuclei  are  clearly  defined 
without  special  preparation.  But  if  this  is  not  the  case,  we  can  always  show 
them  very  nicely  by  again  staining  the  lamella  with  hsematoxylon.  The 
nucleated  spaces  are  cells,  the  brown  lines  are  the  cell-outlines. 

Let  us  recapitulate:  The  lamella  is  here  and  there  thickened.  The  network 
of  cells  is  swollen.  The  basis-substance  is  reduced  in  extent.  The  cell  net- 
work has  become  differentiated  into  smaller  nucleated  portions.  Only  one 
more  step  is  necessary  to  complete  the  occurrence  of  suppuration.  Whenever 
the  basis-substance  has  entirely  disappeared,  the  nucleated  portions  need  only 
to  fall  apart,  and  the  abscess  is  complete. 

The  swelling  and  thickening  of  the  tissue  is  surely  only  the  expression  of 
the  swelling  of  the  cell-network,  for  the  entire  mass  consists  only  of  basis- 
substance  and  cell-network.  But  the  basis-substance  disappears;  therefore 
the  swelling  of  the  cell-network  only  can  be  proportionate  to  the  swelling  of 
the  tissue.  The  swelling  of  the  cell-network  must  accordingly  cause  the 
thickening  and  induration  of  the  tissue.  I  purposely  make  use  of  the  term 
induration  to  indicate  inflammatory  swelling,  and  to  distinguish  it  from 
(edematous  swelling,  which  likewise  occurs  in  inflammations.  Inflammatory 
swelling  (the  induration)  corresponds  with  what  physicians  call  infiltration ; 
with  what  presents  itself  in  cutaneous  abscesses,  for  instance,  as  inflammatory 
hardness;  as  nodules.  I  remark  at  once  that  the  infiltration  may  not  neces- 
sarily be  an  inflammatory  one.  Lupus,  for  example,  forms  analogous  infiltra- 
tions, manifested  as  nodules,  and  the  nodule  in  the  one  case  as  in  the  other  is 
a  preparatory  stage  to  the  destruction  of  the  tissue.  In  fact,  Jarisch  has 
shown1  that  the  microscopical  appearances  of  the  lupus  nodule  correspond 
exactly  with  what  I  have  observed  in  suppurative  keratitis.  The  infiltration 
accordingly  consists  of  a  swelling  of  the  network  of  cells.  The  greater  this 
becomes,  the  more  rigid  is  the  tissue. 

Swelling  is  a  phenomenon  of  growth.  The  growth  of  cells  is  of  course 
only  possible  by  means  of  the  absorption  of  new  matter,  and  this  matter  is 
most  probably  supplied  by  the  blood,  and  we  may  well  call  it  an  exudation, 
in  the  sense  of  the  older  pathologists.  In  this  sense  it  is  •admissible  to  say 
that  the  swelling  arises  from  an  exudation.  But  for  a  comprehension  of  the 
process  it  is  not  indifferent  whether  the  fluid  (the  exudation)  trickles  into  the 
tissue,  or  whether  it  is  absorbed  there  by  the  growth  of  a  branched  living 
body.  The  fluid  which  trickles  into  the  meshes  of  tissues  (as,  for  example, 
into  the  meshes  of  the  subcutaneous  tissue  in  the  neighborhood  of  an  abscess), 
•  an  also  produce  a  swelling;  but  this  is  a  soft,  doughy  swelling.  On  the  other 
hand,  the  cell-network  which  has  become  rigid  by  growth,  is  hard  and  forms 
a  nodule.  (Edema  can  be  made  to  disappear  by  pressing,  but  the  infiltration 
does  not  give  way  in  this  manner.  As  a  rule,  too,  oedema  disappears  as  soon 
as  the  height  of  the  process  is  over;  the  portion  of  the  nodule,  however,  which 
docs  not  Become  disintegrated  (as  a  rule  the  peripheral  portion),  requires  for 
its  complete  retrogression  many  days,  sometimes  many  weeks.  Finally,  the 
cedematous  spots  never  (directly)  suppurate;  a  portion  of  the  nodule  on  the  other 
hand  is,  as  a  rule,  doomed  to  dest  ruction.  Inasmuch  as  the  basis-substance  dis- 
appears; furthermore,  inasmuch  as  the  protoplasmic  masses  which  arise  from 
the  swollen  network  of  cells  subdivide;  and  lastly,  inasmuch  as  the  products  of 
division  fall  apart,  the  nodule  (or  the  infiltration)  is  resolved,  and  the  pus- 
corpuscles  are  the  product  of  resolution. 

1  Archiv  f.  Dermatologie,  1880. 


PATHS   FOR   NUTRITION   AND   SPACES   FOR   COLLECTION   OF   (EDEMA.  33 

By  the  purulent  destruction  of  tissue,  moreover,  not  only  pus-corpuscles 
are  isolated,  but  also  small  granules,  small  shreds  from  the  cell-network,  and, 
in  addition,  larger  pieces  of  tissue  debris — tissue  debris  in  which  the  suppu- 
ration had  not  yet  fully  ripened  when  its  connection  with  surrounding  parts 
was  severed.  Suppuration  is  therefore  a  process  by  which  pus  is  formed.  I 
say  pus,  not  wandering  cells.  Pus,  it  is  true,  contains  wandering  cells,  but 
wandering  cells  alone  are  not  yet  pus.  Pus  is  composed  of  fluid,  of  wandering 
cells,  of  granules,  and  of  tissue  debris.  Where  pus  is  formed  in  the  midst  of 
the  tissue,  the  tissue  must  be  disintegrated.  For  pus  takes  up  space ;  it  fills 
up  the  cavity  of  an  abscess ;  and  in  place  of  the  cavity  and  pus  respectively, 
there  must  formerly  have  been  a  tissue.  The  suppuration,  the  disintegration 
of  the  tissue,  is  prepared  for  by  the  inflammatory  infiltration.  The  cells  and 
their  processes  must  swell.  The  basis-substance  must  disappear  before  disin- 
tegration takes  place.  Hence  the  inflammatory  infiltration  is  preparatory  to 
the  disintegration  of  the  tissue.  "Wherever  the  physician  finds  an  inflamma- 
tory infiltration,  an  induration,  he  must  regard  disintegration,  suppuration, 
as  threatened.  I  say  threatened,  since  the  disintegration  is  not  inevitable. 
In  fact,  the  entire  infiltration  seldom  suppurates,  but  generally  a  central  por- 
tion only.  The  peripheral  zones  are  for  the  most  part  preserved,  and  gradually 
return  to  their  normal  condition.  For  even  if  the  network  of  cells  is  swollen, 
and  the  basis-substance  reduced  ;  as  long  as  no  disintegration  has  taken  place, 
a  restoration  to  the  former  state  is  possible. 

"With  this  explanation  we  have  set  forth  the  principles  of  the  theory  of 
suppuration.  But  it  seems  to  me  advisable  to  discuss  the  subject  still  further. 
In  this  further  discussion,  points  of  view  will  present  themselves  which  will 
be  of  interest  to  the  clinical  teacher,  while  a  clearer  insight  into  the  life  of 
the  organs  may  thereby  be  obtained  by  the  earnest  physician. 


The  Paths  for  Nutrition  and  the  Spaces  for  the  Collection  of  (Edema. 

At  first  I  shall  speak  once  more  of  the  paths  for  nutrition  in  the  tissue. 
According  to  Virchow's  doctrine,  the  cells  anastomosed  with  one  another  and 
through  these  anastomosing  cells  the  nutritive  fluid  was  supposed  to  flow. 
But  at  that  time  cells  were  considered  to  be  hollow  spaces  filled  with  fluid, 
as  they  are  to  be  seen  in  dried  bone.  These  hollow  spaces  were  branched  and 
communicated  with  one  another,  and  it  was  accordingly  believed  that  these 
cells  communicated,  and  that  they  were  the  paths  for  the  nutritive  current. 
When,  at  a  later  period,  Recklinghausen  had  recognized  light  branched  spaces 
in  the  cornea  (and  in  other  similar  tissues)  by  means  of  staining  with  silver, 
he  said  that  these  were  the  nutritive  channels.  Thus  his  hypothesis  was  a 
development,  as  it  were,  of  Virchow's  doctrine.  According  to  the  latter,  the 
nutritive  fluids  passed  through  the  hollow  cells;  but  according  to  Reckling- 
hausen's view  only  through  spaces  in  which  cells  lay,  and  in  which  they  could 
migrate.  When  I  began  to  take  ground  against  the  hypothesis  of  nutritive 
canals  (in  Recklinghausen's  acceptation),  I  thought,  as  I  have  remarked  already 
(page  30),  that  the  nutritive  canals  or  spaces  really  pre-existed,  but  that  they 
were  filled  up.  The  nutritive  fluids,  I  thought,  streamed  through  the  cells, 
and  I  had  thus  really  taken  up  the  doctrine  of  Virchow  again,  with  the  dif- 
ference only  that  I  did  not  say  that  the  nutritive  fluids  flowed  through  hollow 
cells,  but  through  the  protoplasmic  bodies  themselves.  It  was  occurrences  in 
the  protoplasm  itself  which  promoted  the  current. 

In  view  of  this  Irypothesis,  the  supposition  of  spaces  in  the  borders  between 
cells  and  basis-substance,  became  superfluous.  And  yet  a  number  of  argu- 
ments induced  me  not  to  discard  entirely  Recklinghausen's  hypothesis,   "in 

vol.  i. — 3 


34  PATHOLOGY   OF   INFLAMMATION. 

the  first  place,  we  could  inject  the  lifeless  cornea  with  the  aid  of  a  hypodermic 
syringe,  when  the  injected  mass  became  disseminated  through  the  tissue.  In 
the  second  place,  we  were  wont  to  see  real  spaces,  with  shrivelled  cells  lying 
in  them,  in  sections  of  hardened  (contracted)  corneas.  Thirdly,  there  seemed 
to  be  no  doubt  that  amoeboid  cells  could  wander  through  the  cornea. 
Finally,  the  assumption  of  the  existence  of  spaces  in  the  tissue  seemed  indis- 
pensable on  account  of  the  occurrence  of  oedema.  Where  could  the  fluid  of 
oedema  collect,  if  there  were  no  spaces  ?  I  therefore  said  that  the  cells  must 
lie  in  the  spaces  as  the  finger  does  in  a  tight-fitting  glove.  In  these  spaces 
the  fluid  of  oedema  could  collect  and  compress  the  cells.  But,  after  experi- 
ence had  taught  me  that  cell  and  basis-substance  could  displace  their  respective 
borders,  I  came  into  conflict  with  this  hypothesis.  If  a  garden  bordered  on  a 
street ;  if  various  reasons  made  me  believe  that  there  must  be  a  ditch  between 
the  garden  and  the  street ;  if,  finally,  I  learned  that  the  owner  frequently 
displaced  the  garden-fence — now  moving  it  out  towards  the  street  in  order  to 
narrow  the  latter,  now  moving  it  back  again  in  order  to  widen  the  street — if 
I  learned  this,  I  should  be  compelled  to  say  "  I  do  not  understand  how  there 
can  be  a  ditch  there.  This  shoving  to  and  fro  of  the  garden-fence,  this  nar- 
rowing and  widening  of  the  street  is  incompatible  with  the  assumption  of  a 
ditch."  It  is  just  so  with  the  assumption  that  the  cells  lie  in  a  hollow, 
and  that  there  is  a  space,  no  matter  how  small,  between  the  cell  and  basis- 
substance. 

Further  researches,  as  well  as  more  careful  reflection,  have  also  taught  me 
that  the  grounds  which  have  led  to  the  assumption  of  a  system  of  canals  in  the 
cornea,  are  altogether  deceptive.  We  are  taught  in  general  that  the  tissue  can 
become  oedematous ;  but  physicians  know  that  not  all  tissues  are  thus  affected. 
The  conjunctiva  can  become  highly  oedematous.  As  far  as  I  know,  an  oedema 
of  the  cornea  never  occurs.  I  have  likewise  never  seen  an  oedema  of  the  sub- 
stance of  cartilage.  Marked  oedema  only  arises  in  those  tissues  in  which, 
while  fresh,  we  can  recognize  bundles  and  meshes  of  tissue  under  the  micro- 
scope, as  in  the  subcutaneous  and  submucous  tissues.  Pronounced  meshes 
are  also  found  in  the  so-called  interstitial  tissue,  between  the  bundles  of  mus- 
cular fibres,1  and  between  the  tendinous  bundles.  Here,  accordingly,  the  result 
of  microscopical  examination  is  in  accord  with  clinical  experience,  in  accord 
moreover  with  the  fundamental  idea  "oedema,"  since  "oedema"  means  a  con- 
dition such  as  is  caused  by  the  presence  of  fluid  in  the  spaces  of  the  tissue ;  of 
fluid  that  can  be  removed  mechanically  by  pressure.  Such  an  oedema  does 
not  occur  in  the  cornea,  which  agrees  too  with  the  microscopic  picture.  For 
the  most  powerful  microscopes  which  I  now  have  at  command  do  not  enable 
one  to  recognize  in  the  fresh  cornea  even  a  trace  of  fissure  or  cracks.  But  if 
the  (excised)  cornea  lies  for  any  length  of  time  on  the  slide,  then,  it  is  true, 
fissures  are  formed  which  are  readily  recognized,  and  it  is  therefore  compre- 
hensible that  we  can  see  spaces  in  the  shrivelled  cornea,  that  we  can  forcibly 
inject  the  lifeless  cornea,  and  finally,  that  this  can  be  penetrated  by  wandering 
cells. 


The  Apparent  Migration  of  Cells  in  the  midst  of  Tissue,  and  the  Vital 
Processes  in  the  Basis-Substance. 

In  the  normal  cornea  of  the  dog  and  in  that  of  the  cat,  I  have  never  met 
with  an  isolated  cell,  that  is,  a  cell  isolated  from  the  net  of  cells,  in  spots 

1  Do  not  confound  bundles  of  muscular  fibres  with  primitive  fibrillae.     Subsequent  explana- 
tions will  clear  up  this  matter. 


APPARENT   MIGRATION   OF   CELLS   IN    THE   MIDST    OF   TISSUE.  35 

where  the  so-called  fixed  cornea-cells  were  still  preserved,  and  have  never  even 
seen  an  approach  to  forms  which  I  might  call  wandering  cells.  In  the  pa- 
renchyma of  the  cornea  which  is  still  provided  with  branched  cells,  I  have 
until  now  seen  wandering  cells  only  in  the  case  of  the  frog,  and  even  here  I 
was  deceived,  as  new  researches  have  taught  me. 

The  migration  of  cells  in  the  living  cornea  was  discovered  by  Reckling- 
hausen. Now,  if  I  say  that  this  discovery  was  based  on  an  illusion,  the 
reproach  is  applicable  not  alone  to  the  discoverer,  but  to  myself  as  well,  and 
to  all  those  who  have  admitted  the  discovery.  Recklinghausen's  observation 
was  really  one  of  great  excellence,  and  everybody  can  convince  himself  that 
the  forms  which  were  called  wandering  cells,  actually  change  their  position. 
The  essence  of  this  change,  however,  is  not  founded  on  a  migration  of  cells. 
If  somebody  should  show  me  a  mass  of  white,  hardened  wax,  which  he  had 
poured  into  a  metallic  vessel,  and  should  secretly  move  a  flame  slowly  along 
under  the  vessel,  I  might  perhaps  see  a  spot  wandering  along  the  surface  of 
the  wax,  a  spot  which  could  be  recognized  to  be  melted  wax.  I  could  also 
look  towards  the  bottom,  and  matters  might  appear  as  though  a  lump  .of 
melted  wax  were  wandering  through  the  rigid  mass.  But,  in  reality,  the 
wax  would  not  move,  it  would  be  only  the  change  (by  melting)  which  would 
do  so.  In  such  a  case  closer  inspection  would  show  me  that,  on  one  side,  the 
fluid  lump  gradually  hardened  and  assumed  the  character  of  the  remaining 
wax,  whilst,  on  the  other  side,  it  gradually  increased  in  extent  by  the  melting 
of  a  new  mass  of  wax.  The  situation  is  similar  in  the  inflamed  cornea  of  a 
frog.  On  one  side,  the  end  of  a  cell  assumes  the  character  of  the  basis-sub- 
stance ;  on  the  other  side,  a  portion  of  the  basis-substance  which  borders  on 
the  cell  assumes  the  character  of  the  cell.  The  final  result  of  this  change  is 
a  change  in  form  and  position  of  the  entire  cell.1  I  must  remark  here  that 
the  observations  on  which  I  base  the  foregoing  statement  were  made  on  the 
inflamed  cornese  of  frogs,  with  the  slide  heated  up  to  about  38°  C.  [100°. 4  F.].2 
My  preparations  are  made  as  follows:  I  wound  the  cornea  one  or  two  days  before 
the  examination,  according  to  the  season  of  the  year.  About  an  hour  before  the 
examination  I  kill  another  animal,  and  collect  its  blood  in  a  small  saucer.  In 
the  course  of  an  hour  the  blood  is  firmly  coagulated,  and  clear  serum  is  col- 
lected on  the  surface  of  the  clot.  I  draw  this  serum  off  with  the  aid  of  a 
capillary  glass  tube,  and  put  enough  on  the  slide  to  prepare  the  excised  cor- 
nea in  it.  During  the  course  of  the  examination  I  add  a  fresh  drop  of  serum 
from  time  to  time. 

The  observation  that  migratory  cells  become  altered,  and  assume  the  ap- 
pearance of  basis-substance,  is  really  not  new.  It  was  known  long  ago  that 
in  the  building  up  of  the  animal  organism  cells  became  metamorphosed  into 
basis-substance;  but  it  was  believed  that  this  metamorphosis  signified  the 
final  destruction  of  the  cell ;  there  was  likewise  ground  for  the  assumption 
that  this  metamorphosis  only  proceeded  slowly.  For  it  takes  weeks,  months, 
and  at  times  years,  according  to  the  growth  of  the  animal,  until  the  meta- 
morphosis is  effected.  On  the  other  hand,  a  rapid  change  was  not  altogether 
unknown.  If  I  am  not  mistaken,  Recklinghausen  has  already  reported  that 
the  migratory  cells  occasionally  disappear  from  view.  I  spoke  of  it  myself 
in  the  year  1869.3     At  that  time  I  had  already  learned,  from  long-continued 

1  These  observations  are  difficult,  and  liable  to  excite  opposition.  Yet  I  cannot  enter  into  a 
detailed  description  and  proof  in  this  place.  I  have  done  so  in  an  article  which  will  be  pub- 
lished with  the  title  of  "  Zellen  und  Grundsubstanzen"  (Cells  and  Basis-substance).  More- 
over, I  shall  again  return  to  the  subject  in  this  section  (page  36),  and  shall  adduce  other 
observations  which  will  elucidate  from  another  point  of  view  the  assertions  made  in  the  text. 

2  My  heatable  slide  (see  Strieker's  Manual,  American  edition,  p.  57)  did  me  excellent  ser- 
vice here. 

3  Studien  aus  d.  Inst,  fur  exp.  Path. 


36  PATHOLOGY   OF   INFLAMMATION. 

examinations,  that  the  tips  of  cells  or  entire  cells  became  altered  so  as  to  be 
indistinguishable  from  the  basis-substance.  But  I  was  so  prejudiced  by  the 
tradition  that  cells  and  basis-substance  differed  from  each  other,  that  the 
thought  of  a  rapid  metamorphosis  never  struck  me.  Since  a  cell  frequently 
became  visible  in  the  place  where  another  had  disappeared,  I  naturally  pre- 
sumed that  it  was  the  same  one  which  had  previously  vanished.  As  soon, 
indeed,  as  a  study  of  the  appearances  of  inflammation  had  taught  me  that  the 
cells  and  their  processes  extended  their  limits,  and  that,  too,  at  the  expense 
of  the  neighboring  basis-substance,  I  began  to  change  my  opinion  with  regard 
to  the  nature  of  the  latter. 

But  with  difficulty  only  could  I  conclude  to  overturn  the  traditional  ideas 
on  the  nature  and  the  structure  of  basis-substance.  The  basis-substance  was 
said  to  consist  of  fibrilla? ;  the  fibrillar  were  said,  furthermore,  to  be  held 
together  by  a  cement.  And  was  a  cell  to  become  all  this  so  suddenly?  I 
shall  show  hereafter  how  a  study  of  the  various  kinds  of  tissue  has  urged  me 
more  and  more  to  break  with  these  traditional  ideas.  Here  I  will  mention 
only  one  observation,  which  has  finally  induced  me  to  cut  loose  from  this 
view. 

In  a  fresh  condition  and  with  good  illumination,  the  basis-substance  of  the  frog's 
cornea  appears  quite  homogeneous,  though  it  is  different  in  advanced  inflammation. 
In  the  neighborhood  of  the  focus  of  suppuration,  the  basis-substance  becomes  quite 
cloudy,  even  after  the  lapse  of  the  first  days  of  sickness.  If  we  allow  the  inflammatory 
cause  to  act  several  days,1  scarcely  a  single  spot  of  the  basis-substance  remains  homo- 
geneous. Here  and  there  the  basis-substance  looks  as  if  torn  and  destroyed.  It  gives 
the  impression  of  being  converted  into  so-called  detritus.  But  whatever  place  I  may 
bring  into  view  on  the  heating  stage,  I  see  that  the  picture  changes  constantly  every- 
where. The  entire  mass  is  alive.  There  is  present  an  internal  movement  similar  to 
the  one  which  I  have  already  described  as  flowing  motion.  Such  observations,  as  I 
have  remarked,  were  made  on  spots  which  resembled  detritus,  and  in  which  comparatively 
few  cells  were  to  be  recognized.  In  certain  spots  again,  in  such  corneaa,  the  cells  are 
so  densely  packed  that  no  basis-substance  at  all  can  be  seen.  Here  the  cells  still  form 
a  coherent  mass.  In  certain  patches  the  cells  are,  it  is  true,  numerous,  but  there  is 
always  basis-substance  to  be  seen  which  is  not  yet  split  up. 

Now,  again,  we  have  basis-substance  which  is  cloudy,  turbid;  we  can  distinguish 
lighter  and  darker  spots.  If  we  weaken  the  illumination  somewhat  (by  turning  the 
mirrorj,  the  difference  between  the  light  and  dark  portions  becomes  very  plain.  Now 
these  clouds  are  likewise  in  constant  motion;  the  relations  of  light  and  darkness  are 
continually  changing.  At  this  aspect  I  was  at  once  compelled  to  think  of  possible 
illusion.  There  might  be  migrating  cells  lying  over  and  under  the  cloudy  turbidity. 
The  turbidity  might  be  due  to  an  obscuration  by  migrating  cells,  which  might  cause  its 
constant  change.  But  this  interpretation  proved  to  be  wrong.  I  saw  such  cloudy 
appearances  in  places  where  there  were  cells  neither  above  nor  below  them.  In  addi- 
tion, the  cloudy  turbidity  extended  continuously  through  a  considerable  portion  of  the 
basis-substance.  Accordingly,  I  was  compelled  to  refer  the  perceptible  changes  to  the 
basis-substance  itself.  And  in  fact  a  closer  observation  revealed  that  the  cloudy 
turbidity  passed  directly  into  the  amoeboid  cells. 

In  view  of  these  observations  I  was  at  last  compelled  to  cease  doubting. 
During  the  process  of  inflammation,  I  was  now  forced  to  say,  not  only  the 
presumably2  fixed  cells  become  movable,  but  also  the  basis-substance.  It 
thaws,  as  it  were,  from  a  condition  of  rigidity.  Now  I  comprehend  why  the 
tissue  in  its  entirety  suppurates;  I  comprehend  what  is  meant  by  the  inflam- 
matory  resolution  of  tissue.     I  comprehend  the  swelling  up  of  the  network 

1  In  the  cas<>  of  w< '11 -developed  frogs,  during  the  first  days  of  October,  seventy-two  hours  suf- 
ficed. 

2  I  say  presumably.  In  a  subsequent  section  (page  52)  I  shall  show  that  this  assertion  also  is 
not  quite  true. 


SUPPURATIVE   INFLAMMATION   IN   TENDON,   CUTIS,   BONE,   ETC. 


07 


of  cells  at  the  expense  of  the  basis-substance.  The  cells  do  not  consume  the 
basis-substance,  but  the  basis-substance  is  converted  into  cell-body;  is  trans- 
formed again  into  protoplasm. 

By  this  time  I  was  finally  compelled  to  drop  the  assumption  of  fissures 
between  the  cells  and  basis-substance  of  the  cornea.  I  was  forced  to  assume 
that  the  parenchyma  of  the  cornea  was  a  coherent,  living  mass,  which  was 
traversed  by  neither  crevices  nor  fissures.  In  the  living  cornea  no  cells 
migrate ;  the  migration  is  only  apparent.  The  inflamed  cornea  of  the  frog 
is  capable  of  assuming,  at  any  part,  the  appearance  and  peculiarities  of  the 
amoeboid  cell.  Such  a  metamorphosed  spot,  however,  is  not  yet  a  migrating 
cell.  It  does  not  become  a  migrating  cell  before  it  separates  from  its  matrix, 
and  such  a  separation  takes  place  in  mass,  only  in  actual  suppuration.  But 
this  does  not  exclude  the  possibility  of  certain  pieces  being  separated  under 
other  favorable  conditions,  and  of  their  appearing  as  migrating  cells  on  the 
surface  of  the  cornea  or  in  some  pathological  cavity. 

I  shall  return  to  these  new  observations  on  the  phenomena  observed  in  the 
basis-substance,  on  a  subsequent  page  (p.  52).  For  the  present,  what  I  have 
said  will  suffice  to  make  the  subject  of  suppuration  of  the  cornea  fully 
comprehensible. 


Suppurative  Inflammation  in  Tendon,  Cutis,  Bone,  Cartilage, 
and  other  connective  substances. 


In  the  tendon,  the  cells  have  other  forms,  and  a  different  arrangement  from 
that  which  exists  in  the  cornea.  In  the  latter,  the  cells  are  flat  and  their  broad 
sides  lie  parallel  to  the  surface.  Hence  we  see  them  most  advantageously  in 
entire  cornea?,  or  in  lamella?  of  entire  cornea?,  if  spread  out  on  the  slide ;  for 
then  the  cells  present  their  broad  surfaces  to  the  observer.  But  in  tendinous 
tissue,  the  cells  are  composed  of  little  rods,  which  run  parallel  with  the 
fasciculi  of  the  tendon,  and  with  its  long  axis.  The  processes  of  these  cells  arc 
ribbon-like ;  they  pass  out  from  the  rod-like  cells  just  as  flags  do  from  flag- 
poles. In  place  of  the  flat  cells  of  the  cornea,  with  thread-like  processes,  we 
have,  accordingly,  in  the  tendon,  rod-like  cells  (flag-poles),  to  which  on  the 
same  level  numerous  (three  or  four)  flags  are  attached.  These  flags  however 
do  not  wave  free,  but  become  attached  to  the  columns  of  basis-substance 
("  fibrillar  fasciculi,"  these  columns  are  called  here),  and  as  it  were  envelop 
them.  In  my  lectures,  I  demonstrate  this  relation  by  placing  a  white  Avax- 
candle,  as  representative  of  the  fibrillar  fasciculus  or  column  of  basis-sub- 
stance, side  by  side  with  a  red  wax-candle,  as  representative  of  a  cell.  On 
the  free  vertical  border  of  the  red  candle  (flagstaff),  I  attach,  at  each  level, 
several  flags  cut  out  of  red  paper  (Fig. 
7),  and  wrap  them  about  the  white 
candle  so  as  to  inclose  it  as  if  in  a 


sheath. 

In  cross-sections,  these  rod-like  cells 
with  pendant  processes  resemble  flat 
cells  with  thread-like  processes;  in 
short,  resemble  cornea  corpsucles.  In 
the  cross-section  of  a  tendon  stained 
with  gold,  we  therefore  see  a  picture 
analogous  to  that  of  the  lamella?  of  the 
cornea.  In  cross-sections  of  young  ten- 
don, the  cells  are  large,  and  the  "basis- 
substance  (in  this  instance  the  trans- 


C,  cells.    F.  flags.    F' is  called  Boll's  Streifen.  and  is 
nothing  else  than  a  longitudinal  section  of  a  flag. 


38  PATHOLOGY   OF   INFLAMMATION. 

verse  sections  of  fibrillar  fasciculi),  on  the  contrary,  sparse.  The  older  the 
tendon  becomes,  the  smaller  are  the  cells  and  the  thinner  their  processes,  the 
more  extensive  on  the  other  hand  the  basis-substance,  i.  e.  the  fibrillar  fasci- 
culi. These  cells  and  their  processes  are  converted  into  elastic  tissue,  as  has 
been  shown  by  Spina.  The  older  the  tendon  becomes,  the  more  do  the  cells 
assume  the  character  of  elastic  tissue.  Hence  the  great  power  of  resistance 
in  the  tendons  of  old  persons  and  old  animals. 

The  structure  of  the  cutis  is  similar  to  that  of  the  tendon.1  Only  the 
bundles  of  fibrilke,  or,  in  other  words,  the  columns  of  basis-substance,  do  not 
run  parallel  with  one  another  as  in  the  tendon,  but  are  interwoven. 

Waldeyer  was  the  first  to  show2  that  the  basis-substance  in  bone  was  formed 
from  cells  (called  osteoblasts).  It  has  furthermore  been  shown  by  Steudener3 
and  I.  Wolff,4  that,  with  the  increased  age  of  bone,  the  cells  (bone-corpuscles) 
become  smaller,  and  the  basis-substance  between  them  greater.  In  addition, 
Heitzmann  was  the  first  to  prove  fully  that  the  bone-cells  had  processes  which 
traversed  the  basis-substance,  sent  out  numerous  branches  there,  and  anasto- 
mosed with  the  processes  of  neighboring  cells.  The  cavities  in  which  the 
bone-cells  lie,  as  well  as  the  anastomosing  network  of  finest  canalculi  in  which 
the  cell-processes  lie,  were  already  known ;  and  it  was  especially  on  a  knowl- 
edge of  these  facts,  as  has  been  previously  remarked  (page  33  et  seq.),  that 
Virchow  based  his  theory  of  nutrition  of  the  tissues.  Inasmuch  as,  adhering 
to  Schwann's  views,  cells  were  regarded  as  vesicles,  the  small  cavities  in  bone 
could  also  be  considered  as  cells.  Accordingly  we  were  supposed  to  know  of 
anastomoses  of  cells  in  bone,  and  herewith  to  have  a  substratum  for  the 
nutrient  current. 

But  inasmuch  as  the  ideas  of  histologists  on  the  nature  of  the  cell  changed 
in  1861 — inasmuch  as  since  that  time  we  have  not  ventured  to  recognize  the 
presence  of  a  cell  except  upon  seeing  a  protoplasmic  body  with  a  nucleus — 
it  has  become  clear  that  the  cavities  in  the  bone  and  the  canaliculi  are  the 
residences  of  the  cells,  and  not  the  cells  themselves.  In  fact,  the  cells  in  bone 
have  only  been  described  at  a  later  period  by  Krause,5  and  the  protoplasmic 
processes  by  Heitzmann,  as  already  mentioned.  Thus  we  see  a  complete 
analogy  between  bone  and  the  cornea  stained  with  gold.  Here,  as  well  as 
there,  the  cells  and  their  processes  form  a  network  the  meshes  of  which  are 
filled  up  with  basis-substance ;  here,  as  well  as  there,  the  basis-substance  is 
produced  from  the  peripheral  zones  of  the  bodies  of  the  cells.  But  bone  is 
distinguished  from  the  other  analogous  tissues  in  that  lime-salts  are  deposited 
in  the  basis-substance. 

More  difficult  than  in  the  case  of  bone  has  been  the  inquiry  into  the  rela- 
tion of  things  in  cartilage.  And  yet  cartilage  is  the  very  tissue  which  has 
the  greatest  interest  for  us.  This  interest  is  in  the  first  place  historical, 
because  the  earliest  observations  on  inflammatory  metamorphoses  of  tissues 
were  made  on  cartilage  by  G-oodsir  and  Redfern.  Virchow 's  theory,  that 
disturbance  of  the  nutrition  and  function  of  the  cells  was  the  main  criterion 
of  inflammation,  likewise  found  considerable  support  from  an  observation  of 
cartilage.  This  tissue  interests  us,  furthermore,  because  in  certain  portions, 
iit  least,  it  lacks  bloodvessels  and  nerves.  How  are  the  cartilage-cells 
nourished?  How,  moreover,  is  the  inflammatory  process  propagated  in 
cartilage  if  vessels  and  nerves  are  wanting — if  the  cells  besides  (each  com- 
pletely isolated)  are  deposited  in  firm  capsules  of  basis-substance?     Virchow 

1  Tin's  lias  been  proved  under  my  supervision  by  Dr.  Ravogli  of  Rome.  See  Mediz.  Jahr- 
bticher,  1879. 

2  Arcln'v  f.  mikr.  Anatomie,  Bd.  I. 

3  Beitrage  znr  Lehre  von  der  Knochenbildung.     Halle,  ls7.r>. 

*  [Jnters.  liber  d.  Entw.  d.  Knochengewebes.    Leipzig,  1875.  B  Anatomie,  2  Auil.  I. 


SUPPURATIVE   INFLAMMATION    IN   TENDON,   BONE,  CARTILAGE,   ETC.  39 

said  that  the  process  was  propagated  from  cell  to  cell.  I  opposed  this  view 
in  1869.  The  union  of  the  cells  amongst  themselves  I  was  not  yet  familiar 
with  at  that  time,  and  I  could  not  therefore  conceive  how  the  process  pro- 
ceeded from  cell  to  cell. 

An  insight  into  the  method  of  nutrition  of  cartilage  was  nevertheless 
granted  to  me  even  then.  One  of  my  pupils1  had  found  that  by  staining 
hyaline  cartilage  with  osmic  acid  he  could  make  canals  appear,  by  means  of 
which  the  spaces  in  which  the  cells  lay  communicated  with  one  another. 
Another  of  my  pupils2  had  found  that  pigment-granules  could  penetrate  the 
basis-substance  of  living  cartilage.  In  order  to  see  this,  he  pointed  out,  you 
need  only  inject  the  coloring  matter  into  the  blood,  and  then  apply  an  inflam- 
matory stimulus  to  the  cartilage.  I  availed  myself  of  these  discoveries  to 
show  that  there  must  needs  be  a  nutritive  current  in  cartilage.  In  conse- 
quence of  the  stimulus  of  inflammation,  I  said,  this  nutritive  current  becomes 
increased.  The  current  must  come  from  the  blood.  The  nutritive  current 
carries  pigment-granules  along  with  it.  The  pigment-granules  penetrate  the 
cartilage,  and  remain  lying  there ;  they  serve  as  signs  of  the  current  which 
has  passed,  just  as  the  stones  which  are  swept  along  by  the  torrent  and 
carried  off,  remain  lying  somewhere,  and  serve  as  signs  of  the  flood  which  has 
passed  away. 

Closely  connected  with  this  view  of  the  case,  and  based  on  the  researches 
of  one  of  my  pupils,3  was  the  further  assertion  that  the  cartilage-cells  like- 
wise underwent  inflammatory  changes,  as  stated  by  Goodsir  and  Redfern, 
and  as  maintained,  too,  by  Virchow  and  his  followers.  But  my  position 
was  hostile  to  the  theory  of  emigration,  and  hence  the  supporters  of  that 
doctrine  denied  the  capability  of  cartilage  to  participate  in  inflammation. 
In  like  manner,  my  assertion  of  the  penetration  of  coloring  matter  into 
cartilage  was  disputed.  More  recently,  however,  the  penetration  of  coloring 
matter  into  cartilage  has  repeatedly  been  seen,  and  is  now  quite  generally 
admitted.  But  Spina4  has  shown  even  more,  namely,  that  the  pigment- 
granules  advance  through  the  processes  of  the  cartilage-cells.  The  fact  that 
there  was  cartilage  the  cells  of  which  were  united  by  processes,  was  known 
long  ago.  But  that  such  was  the  structure  of  hyaline  cartilage,  that  the 
apparently  structureless,  intermediate  substance  between  the  cartilage-cells 
was  traversed  by  a  system  of  the  flnest  processes,  was  not  known.  Heitz- 
mann5  was  the  first  to  report  the  existence  of  such  ramifications  in  the  basis- 
substance  of  hyaline  cartilage.  He  asserted,  as  early  as  1872,  that  he  could 
see  these  processes  in  the  fresh  condition.  In  addition,  he  has  made  a  very 
fine  network  appear  in  the  immediate  neighborhood  of  the  cells  by  staining 
with  gold. 

But  I  was  not  inclined  to  regard  these  specimens  as  conclusive.  Mean- 
while Spina  has  advanced  new  proofs  of  the  existence  of  such  processes ;  they 
become  visible  when  a  thin  section  of  hyaline  cartilage  is  treated  with  alco- 
hol. Spina6  has  shown,  furthermore,  how  the  cells  of  cartilage  become  con- 
verted into  basis-substance.  I  shall  not  enter  further  into  a  discussion  of  this 
matter,  but  shall  only  remark  that  wo  have  become  familiar  with  a  condition 
of  things  analogous  to  that  in  bone.  On  the  other  hand,  Kassowitz,7  after 
examining  cartilage  in  various  pathological  conditions,  has  made  the  assertion 
that  new  cells  develop  in  the  basis-substance  of  cartilage,  and  that  it  is  itself 
living  matter.  Accordingly  we  now  see  an  analogy  between  cornea,  tendon, 
cutis,  cartilage,  and  bone. 

1  Bubnoff,  Wiener  Sitzungsberichte,  1868.  2  Reitz,  Wiener  Sitzungsberjcbte,  Bd.  55. 

3  Hutob,  Wiener  med.  Jahrbiicber,  1871.  4  Wiener  acad.  Sitzungsber.  1879. 

6  Studien  am  Knorpel  und  Knochen.     Wiener  mediz.  Jabrb.  1872. 

6  Wiener  acad.  Sitzungsber.  1879.  7  Wiener  mediz.  Jahrbucber,  1S79-1880. 


4:0  PATHOLOGY   OF   INFLAMMATION. 

True,  there  are  differences  between  these  kinds  of  tissue.  The  basis-sub- 
stances of  cornea  and  cartilage  appear  homogeneous  throughout  under  the 
microscope,  with  this  difference,  that  we  can  see  the  cells  of  normal  cartilage 
in  a  quite  fresh  condition,  whilst  we  cannot  see  those  of  the  cornea  until  alter 
the  application  of  reagents.  In  these  two  kinds  of  tissue  there  are  no  blood- 
vessels, no  interstices  with  nutrient  fluid;  they  cannot  become  ©edematous. 
Tendon  and  cutis  are  not  as  homogeneous  as  cornea  and  cartilage.  In  tendon 
a  loose  interstitial  tissue,  in  which  the  bloodvessels  run,  extends  along  the 
more  or  less  dense  bundles  of  tissue ;  this  interstitial  tissue  can  become  cede- 
matous.  Accordingly  only  these  more  or  less  dense  bundles  of  tissue  furnish 
us  with  an  analogy  to  the  cornea  as  regards  homogeneousness.  "We  have  a 
similar  condition  in  the  cutis.  But  here,  as  already  remarked,  the  bundles 
of  tissue  do  not  run  parallel  with  each  other,  as  in  tendon,  but  are  interwoven, 
whereby  the  transverse  section  in  the  cutis  acquires  a  very  complicated  ap- 
pearance. 

Bone  is  likewise  traversed  by  vessels,  and  encircling  these  we  have,  now 
abundantly,  now  more  sparsely,  a  tissue  (medullary  tissue),  which  differs 
from  the  real  compact  substance  of  the  bone.  With  respect  to  homogeneous- 
ness, only  the  compact  substance  of  the  bone  is  analogous  to  cartilage.1  In 
fact  it  has  now  been  indisputably  proved2  that  compact  cartilage  customarily 
passes  directly  over  into  compact  bone.  If  cartilage  is  transformed  into  bone, 
canals  must  be  formed  in  the  cartilage,  and  in  these  canals  bloodvessels  must 
be  produced.  The  formation  of  canals  in  cartilage  results  from  a  so-called 
melting  or  liquefaction  (Einschmelzung)  of  the  substance  of  the  cartilage. 
This  liquefaction  may  be  regarded  as  the  physiological  type  of  suppuration. 
It  is  exactly  the  same  process  as  that  which,  in  pathological  conditions,  we 
designate  as  the  formation  of  an  abscess.  The  basis-substance  disappears, 
the  cells  enlarge  and  divide.  In  pathological  conditions,  we  call  the  cavity 
which  is  formed  an  abscess-cavity,  and  the  products  of  division,  pus-cells. 
In  normal  liquefaction  (Einschmelzung)  the  products  of  division  are  called 
medullary  cells,  and  the  cavities,  medullary  spaces.  Similar  conditions, 
moreover,  prevail  in  developed  bone.  The  compact  substance  may  liquefy 
(einschmelzen)  in  the  course  of  normal  development  as  well  as  in  patho- 
logical conditions.  In  the  former  instance  we  speak  of  medullary  spaces 
and  medullary  cells ;  in  the  latter  instance  of  abscess-cavities  and  pus-cells. 

By  the  formation  of  medullary  spaces,  or  of  abscess-cavities,  cartilage  a3 
well  as  bone  becomes  porous  or  spongy.  The  spongy  bone  can  undergo  com- 
plete suppuration  if  the  liquefaction  makes  headway,  if  the  spaces  enlarge. 
On  account  of  the  physiological  peculiarity  of  their  basis-substance,  bone  and 
cartilage  form  a  tissue  sui  generis.  Their  relationship  with  the  cornea,  ten- 
don, and  cutis,  has  until  now  only  been  demonstrated  with  regard  to  the 
relation  of  cell  to  basis-substance. 

In  the  cutis,  as  I  have  said,  the  bundles  of  tissue  do  not  run  parallel  as  in 
the  tendon,  but  are  interwoven.  In  the  cutis,  however,  the  network  forms 
compact  masses,  which  do  not  offer  space  for  the  collection  of  oedema,  as  far 
as  microscopical  examination  enables  us  to  judge  of  the  same.3  Now,  there 
i-  a  scries  oftissu.es  which  consist  of  bundles  analogous  to  those  in  the  cutis, 
but  in  which  the  interlacement  is  so  loose  that  fluid  can  very  easily  permeate 
them.     To  this  class  subcutaneous  and  submucous  tissues  belong.     The  loosest 

1  I  do  not  rcfrr  here  at  all  to  the  complicated  relations  in  bone,  since  I  cannot  enter  into  a 
sufficiently  detailed  account,  and  I  do  not  know,  moreover,  how  much  of  the  known  structure  is 
to  t»'  Been  in  the  living  Bubject. 

2  Lieberkuhn,  Stretzoff,  Kassnwitz. 

8  Within  the  cutis  itself,  however,  such  collections  are  probably  possible  around  the  vessels. 


THEORY    OF   FIBRILLuE   AND   OF   CONNECTIVE   SUBSTANCE.  41 

arrangement  of  this  kind  is  represented  by  the  subarachnoid  tissue.     This 
consists  only  of  single  bundles  which  float  in  the  space  tilled  with  fluid. 

All  of  these  tissues  provided  with  interstitial  meshes,  were  still  called 
cellular  tissue  during  the  first  ten  or  twenty  years  of  our  century.  "Cellular" 
does  not  signify  that  cells  are  present,  in  the  acceptation  of  the  term  as  intro- 
duced into  modern  histology  by  Schwann,  but  that  cell-like,  honeycomb-like 
spaces  are  present.  Job.  Muller  has  introduced  the  expression  "connective 
tissue"  for  this  tissue.  If  we  neglect  the  varying  width  of  the  meshes,  and 
even  the  very  existence  of  the  meshes,  we  in  fact  see  a  columnar  (strangfor- 
mige)  formation  prevailing  in  tendon,  the  tendinous  membranes,  the  cutis,  the 
mucous  membranes,  and  subcutaneous  and  submucous  tissues ;  in  the  mesen- 
tery and  in  other  serous  membranes.  This  columnar  formation  is  peculiar, 
therefore,  to  connective  tissue,  even  where  it  does  not  produce  a  cellular  tissue. 
In  place  of  columnar  formation,  I  shall  henceforth  employ  the  more  usual  term 
of  connective-tissue  bundle.  Accordingly,  connective  tissue  consists  of  bundles 
that  are  united  in  various  ways.  But  every  bundle  consists  of  cells  and  basis- 
substance.  Every  bundle,  whether  large  or  small,  therefore,  forms  a  compact 
mass  similar  to  cornea  and  cartilage.  Every  such  bundle  can  suppurate,  and 
that,  too,  in  the  same  manner  as  described  for  the  cornea. 


Theory  of  Fibrilla  and  of  Connective  Substance. 

Every  bundle  such  as  can  be  made  to  appear  in  tendon,  cutis,  subcutaneous 
tissue,  subarachnoid  tissue,  and  others,  may  also  be  designated  fibrillar  bundle. 
Uow  the  question  of  the  occurrence  and  genesis  of  the  fibrilla?,  constitutes  one 
of  the  most  important  chapters  of  normal  and  pathological  histology.  I  might 
almost  say  it  constitutes  one  of  the  most  important  chapters  of  all  pathology. 
For  that  frightful  host  of  diseases  which  are  designated  as  cicatrizations,  con- 
tractions, scleroses,  and  (in  order  to  make  special  mention  of  only  a  single 
series),  those  severe  forms  of  disease  of  the  central  nervous  system  known  as 
tabes  dorsalis,  lateral  sclerosis,  and  multiple  sclerosis,  which,  though  probably 
only  chronic  inflammations  yet  lead  to  the  destruction  of  life  in  spite  of  all 
remedies,  all  consist  essentially  in  the  formation  of  such  fibrilla?,  or,  still  better, 
of  a  transformation  of  the  nerve  tissue  into  fibrillar  tissue. 

Histologists  had  recognized  the  fibrillar  by  the  examination  of  tissues  that 
were  dried  or  altered  (contracted)  by  reagents.  If  we  soften  in  water  a  dried 
cornea  or  a  dried  tendon,  and  tease  it,  we  will  see  under  the  microscope  very 
fine  fibrilla?,  which  are  arranged  at  times  in  large  bundles,  at  others  in  small 
ones,  or  which  traverse  the  field  of  view  singly  and  in  an  irregular  manner ; 
in  short  we  receive  the  impression  that  the  entire  tissue  consists  of  such 
fibrilla?,  but  that  they  have  been  thrown  into  confusion  by  the  teasing.  On 
the  ground  of  these  observations,  it  was  said :  Cornea,  tendon,  and  cutis  consist 
of  fibrillar  tissue.  On  similar  grounds  we  can  go  further,  and  say  in  general: 
The  connective  tissue  cords  consist  of  fibrilla?,  they  are  bundles  of  fibrilla?. 
More  recently  the  basis-substance  of  macerated  cartilage  and  bone  lias  also 
been  recognized  to  be  fibrillar.  And  thus  we  see  another  analogy  between 
connective  tissue,  on  the  one  hand,  and  bone,  cartilage,  and  cornea,  on  the 
other.  They  all  consist  of  cells  and  basis-substance;  in  the  dried  or  mace- 
rated state  they  all  disclose  a  fibrillar  structure. 

In  the  year  1845,  Eeichert  classified  all  these  tissues,  and  a  series  of  others 
which  I  will  mention  hereafter,  under  the  common  name  of  connective  sub- 
stance. Reichert  in  effect  denied  the  existence  of  fibrilla?  in  a  series  of  tissues. 
It  was  not  the  fibrilla?,  but  a  peculiar  substance,  which  was  characteristic  of 
all  these  tissues.     Thus  the  term  connective  substance  indicates,  as  it  were,  a 


42  PATHOLOGY   OF   INFLAMMATION. 

histological  theory.  The  entire  armament  of  the  older  microscopic  methods 
was  brought  to  bear  on  this  assertion  of  Reichert.  In  the  first  place  it  was 
Alex.  Rollett,  who,  under  Briicke's  direction,  demonstrated  the  existence  of 
these  fibrillse  in  spite  of  Reichert's  assertion.  The  fibrillse,  he  said,  are  united 
by  an  albuminoid  cement.  If  we  preserve  the  cutis  in  lime-water,  or  in 
baryta-water,  the  cement  is  dissolved,  and  the  fibrillse  fall  apart.  These 
results  agreed  with  the  tendencies  of  the  microscopists  of  that  time,  and  a 
large  majority  of  histologists  take  this  standpoint  even  at  the  present  day. 
The  doctrine  of  the  fibrillar  structure  of  connective  tissue  appeared,  and  still 
appears,  to  stand  on  a  solid  foundation.  The  disclosure  of  fibrillse  in  bone  by 
Ebner,1  followed  entirely  in  the  spirit  of  the  method  by  which  Rollet  had 
demonstrated  the  existence  of  fibrillse  in  the  cornea.  It  was  the  old  method 
of  examining  macerated  tissues.  "We  are  very  much  indebted  to  these  methods. 
By  their  aid  histology  acquired  its  first  solid  foundations.  The  examination 
of  contracted  and  macerated  specimens  is  indispensable  even  to-day,  and  will 
remain  so,  perhaps,  for  all  time.  But  the  results  must  be  checked  by  the 
examination  of  living  tissues ;  by  the  examination  of  tissues  at  various  ages 
of  their  growth ;  and  finally  by  the  examination  of  the  tissues  in  pathological 
conditions.  Neither  the  cornea,  nor  the  tendon,  nor  the  cartilage,  permits  of 
the  recognition  of  fibrillse  in  the  fresh  state.2  The  basis-substance  appears 
homogeneous  in  all. 

Now  the  objection  may  be  raised  that  this  proves  nothing.  The  basis-sub- 
stances appear  homogeneous,  because  the  fibrillse  are  united  by  a  cement ; 
because  fibrillse  and  cement  possess  the  same  optical  properties.  If  I  deny 
the  existence  of  fibrillse  on  account  of  the  homogeneous  .appearance  of  the 
basis-substance,  I  must  likewise  deny  the  existence  of  the  cornea-corpuscles, 
it  may  be  said.  For  the  fresh  cornea  shows  no  structure  at  all ;  it  is  of  a 
glassy  brightness.  Must  we  not  admit  nevertheless  that  the  network  of  cells 
does  exist,  but  that  we  do  not  see  it  because  it  possesses  the  same  optical 
properties  as  the  basis-substance?  Now  this  is  a  very  weighty  objection,  but 
it  is  open  to  discussion,  and  in  order  to  elucidate  this  question  I  shall  next 
introduce  a  few  remarks  on  the  cell-nucleus. 


On  the  Cell-Nucleus. 

If  we  examine  an  amoeboid  white  blood-corpuscle  of  the  frog,  we  will  at 
times  see  nuclei,  and  at  times  not.  A  more  accurate  examination  teaches  us3 
that  the  nuclei  come  and  go;  that  new  nuclei  also  are  formed,  now  in  this, 
now  in  that  part  of  the  cell.  It  happens  furthermore  that  on  one  side  a  nu- 
cleus gradually  acquires  the  character  of  the  cell-body,  while  on  the  other 
side  a  new  addition  is  made  to  the  nucleus  from  out  of  the  cell-body.  But 
as  soon  as  we  add  acetic  acid,  nuclei  immediately  arise  in  definite  shapes, 
in  shapes  that  were  previously  not  present.  This  configuration  is  now  a 
lasting  one,  since  cell  and  nucleus  have  become  lifeless.  The  nuclei  as  they 
appear  in  reaction  with  acetic  acid  have  been  known  long  since.  If  anybody 
had  asserted  twenty  years  ago  that  such  nuclei  did  not  exist  in  the  living 
while  blood-corpuscles,  the  assertion  would  certainly  have  been  regarded  as 
entirely  unjustifiable.  Now  matters  are  different.  The  assumption  of  the 
appearance  and  disappearance  of  nuclei  in  certain  varieties  of  cells,  is  almost 

1  The  (llir ilia;  of  bone  were  known  before  this  ;  Waldeyer  Lad  described  them  in  Max  Schultze's 
Archiv,  Bd.  i. 

2  Examined  in  aqueous  humor  immediately  after  excision. 

3  First  observed  by  Arndt,  and  then  by  myself  (Wiener  mediz.  Jahrhucher,  1878).  But  the 
reader  must  refer  to  my  article,  since  there  are  several  varieties  of  colorless  blood-corpuscles. 


FIBRILLAR   AND   OTHER   CONNECTIVE   SUBSTANCES.  43 

universally  admitted.  The  zoologists  even  say  that  my  observation  is  not  at 
all  a  new  one ;  that  they  were  familiar  with  this  phenomenon  long  ago,  in 
the  case  of  the  lowest  animal  forms.  Thus,  in  spite  of  the  majority  of  cells 
(for  example,  young  epithelial  cells)  having  recognizable  nuclei  in  the  living 
specimen ;  in  spite  of  the  nucleus  being  still  regarded  as  an  attribute  of  the 
cell,  it  is  nevertheless  admitted  that  there  are  cells  in  which  the  nucleus  is 
not  a  constant  factor — in  which,  at  times,  there  is  no  nucleus  at  all  present.} 
Furthermore,  a  majority  surely  of  all  pathologists  admit  that,  during  the' 
process  of  inflammation,  nuclei  appear  in  such  large  numbers  as  to  exclude 
every  doubt  of  their  new  formation. 

Now  one  might  say  that  this  is  just  the  condition  of  things  in  the  case  of 
the  network  of  cells  in  the  cornea.  It  is  true  that  cartilage  and  some  other 
tissues  enable  us  to  recognize  cells  in  the  living  specimen;  it  is  true,  like- 
wise, that  we  can  regularly  make  cells  appear  in  the  cornea  by  the  use  of 
reagents;  it  is  true  that  we  can  also  see  them  in  the  inflamed  cornea  in  a  fresh 
state.  But  from  the  instances  already  cited,  we  cannot  conclude  with  cer- 
tainty that  they  exist  in  the  normal  cornea. 

However,  I  have  made  new  observations  on  this  matter,  and  when,  on  a 
subsecment  page,  these  observations  are  mentioned,  I  shall  revert  to  the  matter 
in  hand.     But  before  doino;  so  I  must  consider  a  series  of  other  tissues. 


Comparison  between  the  supposed  Fibrillar  Substances  and  the  other 

Connective  Substances. 

A  series  of  tissues,  the  structure  of  which  is  essentially  different  from  that  of 
those  already  mentioned,  is  likewise  included  in  the  list  of  connective  sub- 
stances; I  mean  the  so-called  framework  of  the  brain  and  spinal  cord  (neu- 
roglia, Virchow),  and  the  so-called  adenoid  tissue  in  the  lymphatic  glands. 
This  tissue  consists  of  cells  and  their  processes,  the  latter  being  branched  and 
forming  an  extensive  network.  The  network  is  really  the  characteristic  part 
of  the  tissue.  The  cells  (points  of  junction  of  the  network)  are  entirely  ab- 
sent in  certain  parts,  as,  for  example,  in  the  sinus  of  lymphatic  glands.  Since 
fibrillar  were  regarded  as  characteristic  of  the  connective  substance,  one  was 
inclined  to  suppose  that  this  mesh  work  took  the  place  of  the  fibrillar  But 
the  meshwork  of  the  adenoid  substance,  as  well  as  that  of  the  neuroglia,  is 
on  the  other  hand  analogous  to  the  network  of  cells  in  the  cornea,  in  bone,  in 
tendon,  etc. ;  while  the  fibrillae  into  which  the  latter  tissues  appear  split  (after 
maceration)  traverse  the  basis-substance  like  the  threads  of  woven  cloth. 
Hence  the  network  of  the  adenoid  substances  and  of  the  central  nervous 
system  cannot  be  regarded  as  analogous  to  the  fibrillae  of  the  connective 
substances.  The  analogy  between  these  tissues  must  be  sought  for  in  other 
points. 

In  the  lymphatic  glands,  the  meshes  of  the  network  are  filled  with  a  fluid 
in  which  the  lymph-corpuscles  float,  whence  the  whole  tissue  is  so  soft  and 
spongy.  In  the  gray  matter  of  the  brain  and  spinal  cord,  the  network  is 
filled  with  a  mass  which  we  do  not  thoroughly  understand ;  with  a  mass  which 
gives  to  the  gray  matter  its  peculiar  consistence.  In  the  white  matter  of  the 
brain  and  spinal  cord,  the  meshes  of  the  network  are  adapted  to  the  nerve-> 
fibres;  in  other  words  the  nerve-fibres  are  stuck  into  a  net  of  connective  sub- 
stance. It  is  probable,  furthermore,  that  in  the  cornea,  in  bone,  in  cartilage, 
in  tendon,  etc.,  the  meshes  are  filled  with  something  that  gives  to  each  of 
these  tissues  a  characteristic  physical  state.  In  bone,  for  example,  it  is  the 
lime-salts  mixed  perhaps  with  other  substances.  We  see  accordingly  that,  in  a 
lifeless  condition,  each  of  these  tissues  belonging  to  the  connective  substances 


44  PATHOLOGY   OF   INFLAMMATION. 

shows  cells  under  the  microscope,  besides  a  network  of  processes  and  an 
intercellular  substance.  If  the  cornea,  or  the  cord  of  the  tendon,  has  fallen 
apart  into  fibrillar  the  cleavage  extends  through  the  entire  basis-substance,  as 
was  first  recognized  by  Heitzmann ;  it  implicates  the  network  as  well  as  the 
intercellular  substance.  Only  the  cell-bodies  themselves  (the  points  of  junction 
of  the  network)  withstand  the  cleavage  here  and  there.     Hence  also,  histolo- 

tists  of  former  times  taught  that  connective  tissue  consisted  of  bundles  of 
brils  and  of  connective-tissue  corpuscles. 


The  Transversely  Striped  Muscular  Fibres  ;  Continuation  of  the 
Discussion  on  the  Nature  of  the  Fibrill^e. 

The  property  of  being  resolved  into  fibrillre  belongs  not  only  to  the  con- 
nective substances,  but  also  to  other  varieties  of  tissue.  It  has  been  made 
known  (by  Briicke  if  I  mistake  not)  that  transversely  striped  muscles  which 
have  been  preserved  in  alcohol,  are  very  easily  separated  into  very  fine  fibrilla?. 
This  method  of  preparation  presents  us  with  really  splendid  pictures  of 
bundles  of  fibrillre.  Each  fibril  shows  the  rudiments  of  the  transverse  stria- 
tion,  and  accordingly  looks  like  a  string  of  beads.  On  this  account,  too,  we 
call  the  transversely  striped  muscular  fibres,  bundles  of  primitive  fibrils.  All 
the  strings  of  beads  together  make  up  the  bundle,  the  muscular  fibre,  this 
lying  in  a  closed  sac  (the  sarcolemma)  which  is  everywhere  closely  adherent. 
Formerly,  every  such  fibril  was  thought  to  consist  of  a  series  of  little  rods 
(sareous  elements),  that  were  united  by  a  kind  of  cement,  an  intermediate  sub- 
stance. As  long  as  the  fibrils  cohere,  it  was  said,  they  present  the  appearance 
of  transverse  striation,  because  a  number  of  sareous  elements  with  intermediate 
substance  are  arranged  in  juxtaposition,  and  run  in  a  transverse  direction. 
But  it  was  supposed  that  the  muscular  fibre  could  be  divided  into  disks,  as 
well  as  into  fibrils.  Muscles  of  the  hydrophilus,  preserved  in  dilute  muriatic 
acid,  present  such  an  appearance.1  Every  such  transverse  disk,  consisting  only 
of  sareous  elements,  was  called  a  Bowman's  disk.  Following  Briicke  and 
Rollett,  Bowman's  disks  also  received  the  name  of  chief  substance  (Hauptsub- 
stanz)  and  the  cement  between  them  that  of  intermediate  sidstance. 

During  the  last  fifteen  years,  however,  the  theory  of  the  structure  of  muscles 
has  materially  changed.  During  this  period,  so  many  new  and  contradictory 
views  on  this  subject  have  been  published,  that  I  am  scarcely  able  to  form  a 
clear  idea  of  the  state  of  literature  on  the  question.  Therefore  I  cannot  give 
a  general  survey  of  it,  and  I  have  no  inclination  to  do  so.  I  believe  that  the 
histologists  who  are  at  the  present  day  quarrelling  about  the  presumably  very 
complicated  structure  of  muscles,  are  on  a  wrong  path.  I  have  conclusive 
proof  that  muscle  (as  far  as  its  perceptible,  microscopic  structure  is  concerned) 
is  very  simply  formed.  But  I  should  like  to  support  the  description  I  intend 
to  give  by  first  drawing  the  following  picture.  In  the  transversely  striped 
muscle,  the  appearance  of  things  is  at  times  somewhat  the  same  as  in  a  dance. 
The  couples  change,  and  the  grouping  varies.  Whoever  does  not  observe  the 
changes,  will,  it  is  true,  always  sec  dancing  couples.  Nevertheless  they  are  not 
always  I  he  same  couples.  And  it  may  happen  that  at  one  time  only  single 
pairs  are  dancing;  at  another  time  two  pairs  are  grouped  together;  then 
again  several  pairs.  The  dancers  may  resolve  themselves  into  rows  walking 
in  single  file  (fibrillar),  or  may  form  a  broad  front  and  march  in  columns. 
Finally,  they  may  break  up  the  dance  and  move  about  without  regular  order, 
or  may  remain  quiet  after  breaking  up. 

1  But  as  a  rule  several  disks  adhere  together  in  the  specimens. 


TRANSVERSELY   STRIPED   MUSCULAR   EIERES.  45 

If  we  look  at  the  freshly  excised  (living)  muscle  from  the  extremity  of  a 
Hydrophilus  piceus,  we  can  observe  transformations  which  correspond  to  the 
picture  just  drawn.  The  muscle  of  the  aforesaid  insect  still  makes  very  active 
movements  under  the  covering  glass  of  a  slide.  The  mass  of  the  muscle 
undulates  to  and  fro,  as  it  were,  and  the  details  therefore  cannot  be  readily 
perceived.  When  it  has  become  somewhat  quieter,  we  can  see  so-called  con- 
tractile waves  proceed  along  single  fibres;  a  knot,  a  protuberance,  apparently 
passes  along  the  muscular  fibre.  If  the  muscular  fibres  have  remained  any 
length  of  time  on  the  slide,  very  peculiar  phenomena  make  their  appearance, 
which  are  probably  pathological,  because  they  are  the  forerunners  of  death. 
Some  of  the  muscular  fibres  suddenly  become  converted  into  bundles  of  fibril- 
lar, suddenly  the  fibrillar  structure  disappears,  and  the  broad  ribbon-like 
character  returns  in  its  stead.  Then,  again,  we  see  variations  in  the  breadth 
of  the  ribbons,  and  in  their  distances  from  each  other.  In  addition,  the  in- 
ternal structure  of  the  broad  bands  changes.  At  times,  such  a  band  is  bright 
in  the  middle  and  dark  at  the  lateral  zones;  at  times  the  condition  is  re- 
versed. The  dark  zones  appear  granular  and  irregularly  bordered  at  one 
time,  and  at  another  homogeneous.  Suddenly  the  transverse  striation  disap- 
pears in  a  fibre,  and  it  assumes  a  fibrillar  structure.  Then  the  fibrillar  are 
suddenly  lost  to  sight,  and  the  muscular  fibre  looks  like  a  homogeneous  mass 
provided  with  granules.  A  renewed  undulation  and  we  have  again  the 
ribbon-like  appearance. 

As  long  ago  as  the  year  18 70,1 1  gave  a  similar  description  in  my  Manual 
of  Histology.  The  more  modern  histological  school,  however,  has  scarcely 
taken  any  notice  of  this  description.  A  number  of  distinguished  histologists, 
then  as  well  as  since,  have  described  certain  of  the  variable  phenomena  as  the 
structure  of  the  muscle,  and  in  this  state  of  affairs  it  is  comprehensible  that 
very  different  views  should  prevail.  One  of  my  pupils  (Heppner)  has  ac- 
counted for  some  of  the  variable  phenomena  on  the  ground  of  optical  illusions. 
But  I  must  now  acknowledge  that  I  myself  was  deceived  in  this  respect. 
There  are  no  optical  illusions  in  question  here.  What  Hensen,  Krause,  En- 
gelman,  Merkl,  and  other  histologists  have  described  in  the  muscle,  is  really 
based  on  fact,  but  the  fact  itself  is  not  constant.  The  muscles  of  the  trunk 
of  the  frog,  and  also  those  of  mammalia,  are  not  as  changeable  as  the  muscles 
of  insects.  In  the  former  instance  the  condition  is  really  one  of  stability  as 
long  as  the  tissue  is  normal;  but  as  soon  as  the  muscle  of  the  frog  has  an 
inflammatory  stimulus  applied  to  it,  the  stability  ceases.  True,  no  such 
movements  arise  as  in  the  Hydrophilus  muscle.  There  is  a  slow  displace- 
ment— a  displacement  such  as  I  have  called  internal  flowing  motion  in  the  case 
of  the  white  blood-corpuscle.  Moreover,  when  a  muscle  is  about  to  suppurate, 
the  internal  changes  become  more  striking.  The  muscle  loses  its  transverse 
striation,  the  nuclei  increase  in  number,  and  finally  the  transversely  striped 
muscular  fibre  is  converted  into  a  mass  of  young  cells  or  pus-corpuscles. 

Such  changes,  and  others  which  are  analogous,  have  been  repeatedly  seen 
since  the  time  of  Bardeleben  (1842),  in  inflammatory  and  non-inflammatory 
new  formations  in  muscle.  Otto  Weber,  Waldeyer,  Tchanisky,  and  C.  Weil 
(the  two  latter  under  my  direction),  and  many  other  authors,  have  given  ac- 
counts of  such  processes.  More  recently,  the  inflammatory  processes  have 
been  again  very  accurately  studied  by  Spina,  who  has  found  that  not  only 
pus-corpuscles,  but  also  blood-corpuscles,  can  be  developed  from  the  trans- 
versely striped  muscular  fibre.2 

1  Strieker's  Manual,  American  edition,  pages  1086,  1087. 

*  A  similar  discovery  in  the  case  of  carcinomatous  degeneration  of  the  muscles  of  the  tongue 
dad  previously  been  made  by  C.  Weil. 


46  PATHOLOGY   OF   INFLAMMATION. 

These  observations,  now,  force  me  to  hold  the  following  view:  The  mus- 
cular tibre  is  a  contractile  mass  surrounded  by  a  tube  (sarcoli  mma),  a  contrac- 
tile mass  which,  at  the  time  of  a  normal  discharge  of  function,  has  the  peculiar 
appearance  of  transverse  striation,  or  more  correctly,  of  possessing  transverse 
bands.  But  it  is  only  a  certain  arrangement  of  the  contractile  substance 
which  gives  it  this  appearance;  an  arrangement  consisting,  perhaps,  only  of 
a  varying  density1  of  the  mass.  This  arrangement  can  vary  according  to  the 
order  to  which  the  animal  belongs,  and  according  to  the  function  of  the 
muscle.  It  can  lead  to  all  the  changing  appearances  which  have  been  de- 
scribed by  histologists.  In  the  fresh  (living)  specimen,  the  muscle  can  resolve 
itself  into  fibrilla?,  and  it  is  probable  that  the  fibrilla?  which  are  to  be  seen  in 
specimens  preserved  in  alcohol,  made  their  appearance  just  previous  to  death. 
The  best  proof  of  the  fibrillar  change  of  the  living  muscles  is  offered  by 
pathological  processes,  especially  by  inflammation,  as  has  been  shown  in  a 
most  exhaustive  way  by  Friedreich.2  The  fibrillar  change  in  disease  can^also 
be  regarded  as  a  fibrillar  degeneration,  as  a  destruction  of  the  muscle.  Be- 
sides,  we  know  still  another  form  of  destruction  of  the  muscular  structure. 
The  muscle  may  lose  its  peculiar,  transversely-striated  appearance,  and  become 
a  homogeneous,  granular  mass.  Such  an  appearance  of  the  muscles  has  in- 
duced those  pathologists  who  always  examine  only  lifeless  tissues,  to  believe 
that  the  homogeneous  appearance  is  a  sign  of  the  death  of  the  fibre.  But  the 
muscular  fibre  can  continue  to  live  as  a  homogeneous  mass.  Its  nuclei  can 
multiply;  it  can  suppurate ;  it  can  become  converted  into  blood-corpuscles ;  it 
can  produce  fat-granules.  Various  circumstances  even  seem  to  indicate  that 
it  may  regain  its  normal  state  after  a  loss  of  the  transverse  striation. 

After  this  explanation,  I  return  once  more  to  the  question  of  the  nature  of 
the  fibrilla?.  Is  the  living  muscle  fibrillar  ?  Does  the  muscular  fibre  consist 
of  a  bundle  of  fibrilla?  ?  We  can  now  scarcely  answer  this  question  affirma- 
tively. And  yet  we  must  admit  that  there  must  be  something  contained  in 
the  muscle  to  permit  of  its  changing  into  fibrilla?  under  the  influence  of 
certain  stimuli.  If  we  stain  the  living  muscular  fibre  with  chloride  of  gold, 
we  recognize  a  fibrillar  structure  in  the  specimen ;  indeed,  here  the  fibrilla? 
or  little  bundles  of  fibrilla?  seem  united  by  an  intermediate  substance  of  a 
deep  violet  color.  This  arrangement  has  been  the  subject  of  numerous  dis- 
cussions. Gerlach3  has  asserted  that  these  deep  violet  tracings  between  the 
fibrilla?  are  the  continuations  of  the  nerves.  But  Gerlach 's  assertion  has  been 
denied  in  various  quarters.  I  must  confirm  the  fact  that  there  is  a  continuity 
between  the  threads  of  the  terminal  nervous  apparatus  (which  are  likewise 
stained  a  deep  violet  color)  and  the  afore-mentioned  violet  intermediate  sub- 
stance. But  that  we  have  here  really  to  deal  with  the  continuations  of  the 
nerve,  I  do  not  dare  to  assert.  There  is  a  stage  in  the  course  of  the  inflam- 
matory process  in  which  the  entire  mass  of  the  muscle  has  already  changed 
its  ap] learance.  The  transverse  stripes  have  already  disappeared ;  the  approach 
to  suppuration  is  already  declared;  nothing  more  is  to  be  seen  of  the  violet 
tracings,  but  the  terminal  nervous  expansion  of  Kiihne4  is  still  to  be  seen 
distinctly,  and  almost  unchanged.  Considering  this,  I  must  now  admit  that 
in  the  muscular  fibre,  alongside  of  the  main  mass  (the  contractile  substance), 
there  is  distributed  still  another  substance  which  stains  of  a  deep  violet  color 
— a  substance  which  perhaps  favors  the  separation  into  fibrilla?.    The  question 

1  The  beautiful  color  phenomena  seen  with  polarized  light  (Briicke)  are  well  calculated  to 
support  this  view. 

2  Qeber  progressive  MuBkelatrophie.    Berlin,  1873. 

3  Max  Schultze's  Archiv,  Band  xiii. 

4  This  is  the  terminal  nervous  expansion  situated  between  sarcolemma  and  the  contractile 
substance,  and  was  discovered  by  Kiihne.     [Note  of  the  Translator.] 


SMOOTH   MUSCULAR   FIBRES   AND   THE   CENTRAL   NERVOUS    SYSTEM.  47 

of  the  nature  of  this  substance  is  undecided,  as  is  also  the  question  of  how 
this  substance  is  distributed  in  the  living  muscular  fibre. 

As  regards  the  fibrillar,  we  have  not  yet  reached  a  decision.  For  the 
present,  let  us  remember  that  the  fibrillar  may  appear  and  disappear  again  in 
the  living  muscle,  and,  furthermore,  that  in  disease  the  muscular  fibre  can  be 
definitively  transformed  into  fibrillar  bundles,  not,  however,  losing  thereby 
its  functional  power.  And,  relying  upon  these  and  other  experiences,  we 
will  soon  obtain  a  definitive  answer. 


The  Smooth  Muscular  Fibres  and  the  Central  Xeryous  System. 
Continuation  of  the  Discussion  on  the  Fibrill^e. 

A  more  searching  criticism  of  the  hypothesis  of  the  pre-existence  of  the 
fibrillar,  is  furnished  us  by  those  tissues  which  normally  never  appear  fibrillar, 
whether  examined  in  a  fresh  or  in  a  macerated  state,  though  it  is  true  that 
they  may  become  fibrillar  when  subjected  to  pathological  changes.  To  this 
class  belong : — 

(1)  The  Smooth  ITuscidar  Fibres. — In  the  normal  state  we  recognize  the 
smooth  muscular  fibres  as  spindle  cells  with  oblong  nuclei.  In  case  of  sup- 
puration, the  smooth  muscular  fibres  may  subdivide  and  form  pus-corpuscks. 
But  there  is  a  regular  series  of  chronic  processes  in  which  they  are  changed 
into  fibrillar  The  close  relationship  between  fibroma  and  myoma  is  based  on 
these  transitions.  In  such  neoplasms,  we  find  undivided  (non-fibrillated) 
smooth  muscular  fibres  next  to  bundles  of  fibril  he.  Hence  we  may  be  in 
doubt  as  to  whether  we  have  to  deal  with  a  fibroma  or  a  myoma,  according 
as  one  or  the  other  tissue  is  more  abundant. 

(2)  The  White  and  Gray  Matter  of  the  Central  Nervous  System. — I  have 
already  stated  that  the  medullated  fibres  of  the  white  matter  are  stuck  into 
a  filamentous  network  of  connective  substance.  ■  This  network  is  directly 
continuous  with  that  fine  network  which  constitutes  the  neuroglia  of  the 
gray  matter.1  In  the  gray  matter,  however,  the  network  is  filled  up  with  a 
mass  which,  in  the  living  specimen  perhaps,  is  homogeneous,  but  which 
appears  finely  granulated  in  hardened  preparations.  This  fine  network,  plus 
the  mass  in  its  meshes,  constitutes  the  basis-substance  of  the  brain  and  spinal 
cord.  In  this  basis-substance  the  ganglion  cells  and  their  processes  are 
situated.  These  processes  are  of  two  kinds,  as  was  first  shown  b}-  Deiters.2 
In  the  first  place,  we  have  axis-cylinder  processes,  such  processes  as  penetrate 
the  white  matter  and  become  the  axis-cylinders  of  the  medullated  fibres.  In 
the  second  place,  the  ganglion-cells  send  out  processes  which  form  connections 
with  the  network  of  the  neuroglia.  These  processes  were  called  by  Deiters 
protoplasma  processes.  Besides  the  ganglion-cells,  we  meet  with  other  cells 
in  the  gray  matter,  concerning  the  nature  of  which  we  are  not  quite  clear, 
and  the  processes  of  which  are  likewise  continuous  with  the  network.  Many 
of  these  cells  are  called  connective-tissue  corpuscles. 

As  I  cannot  here  enter  into  the  discussions  on  the  minute  structure  of 
the  gray  matter,3  I  rest  satisfied  with  this  description,  and  recapitulate  as 
follows :  In  the  gray  matter  there  are  ganglion-cells  and  other  cells,  the  pro- 
cesses of  which  form  a  fine  network.  The  network,  plus  the  mass  in  its 
meshes,  constitutes  the  basis-substance.  But  there  are  also  processes  which 
originate  in  the  ganglion-cells,  pass  directly  into  the  white  matter,  and  con- 

1  This  network  is  identical  with  the  substance  called  "  neuroglia"  by  Virchow.  It  was  first 
accurately  described  by  Bidder  and  Kupffer.     See  the  history  in  my  Lectures,  p.  561  et  seq. 

2  Untersuch.  iiber  Gehirn  und  Ruckeninark.     Braunschweig,  1865- 
8  See  my  Lectures  ;  Lect.  xxxii.  p.  5til  et  seq. 


48  PATHOLOGY    OF   INFLAMMATION. 

stittite  the  axis-cylinders  of  the  medullated  fibres.  In  addition,  tlie  network 
of  neuroglia  in  the  gray  matter  is  continuous  with  the  network  of  neuroglia 
in  the  white  matter.  In  the  white  matter,  however,  the  network  is  not  filled 
up  with  a  granular  mass,  but  the  meshes  of  the  network  adapt  themselves  to 
the  nerve-fibres.  The  cells  in  the  neuroglia  of  the  white  matter  are  sparse 
and  very  small. 

Besides  the  network  of  neuroglia,  another  network  is  found  in  the  white 
matter,  namely  in  the  medullary  layer  of  the  nerves.  This  network  was  dis- 
covered by  Kiihue  and  Ewald.1  The  medullated  fibre  consists  of  the  axis- 
cylinder,  of  the  medullary  layer,  and  of  a  structureless  sheath  (Schwann's 
sheath)2  which  limits  the  medullary  layer  externally.  Now  it  is  the  medul- 
lary layer  which  contains  the  aforementioned  net.  The  meshes  of  this  network 
are  here  filled  with  the  peculiar  substance  that  we  call  medullary  substance. 
This  is  a  substance  rich  in  fat,  which  lends  to  the  entire  nerve  its  opacity. 
If  we  wish  to  see  the  network,  we  must  extract  the  fat  with  alcohol  and  ether, 
or  with  alcohol  and  turpentine.  Having  deprived  a  peripheral  nerve  (for 
example,  the  sciatic  nerve  of  the  frog)  of  its  fat,  we  recognize  with  a  magni- 
fying power  of  300  diameters,  or  better  still,  with  a  higher  power,  that  the 
space  between  the  axis-cylinder  and  Schwann's  sheath  is  traversed  by  a  knotted 
network ;  by  a  network  whose  meshes  now  (after  the  extraction  of  the  fat) 
are  light  and  transparent,  thus  making  the  trabecular  of  the  network  very 
plainly  visible.  This  network  is  inserted  on  one  side  into  the  axis-cylinder,  on 
the  other  side  into  Schwann's  sheath.  Similar  networks,  though  not  as  sharply 
defined,  are  also  contained  in  the  medullary  layers  of  central  nerves,  and  in 
the  white  matter  of  the  brain  and  spinal  cord.  But  not  all  the  nerve-fibres 
of  the  white  matter  are  medullated.  We  have,  in  this  respect,  the  most  varied 
gradations,  from  nerves  with  a  very  thick  medullary  layer  down  to  nerves 
with  a  very  thin  one,  and  even  axis-cylinders  which  do  not  show  the  presence 
of  a  medullary  layer  at  all.  Transverse  sections  of  the  spinal  cord  of  man,  or 
of  the  dog,  which  have  been  hardened  in  a  two  per  cent,  solution  of  chromic 
acid,  and  then  in  alcohol,  show  these  relations  very  plainly,  especially  if  they 
have  been  washed  well  and  stained  in  carmine.  For  the  network  of  connective 
tissue  as  well  as  the  axis-cylinders  are  stained  red  by  carmine,  whilst  the  me- 
dullary layers  remain  almost  colorless. 

If  we  cause  inflammation  and  suppuration  in  the  spinal  cord  of  a  dog, 
by  means  of  injury,  and  then  prepare  it  in  the  manner  described,  we  learn 
as  follows :  In  the  immediate  neighborhood  of  the  suppurating  spots,  the 
axis-cylinders  are  thickened.  This  thickening  is  very  unequal.  We  find 
axis-cylinders  which  are  about  as  thick  as  a  connective-tissue  cord  of  the  cutis, 
and  all  gradations  down  to  the  thinnest  axis-cylinders  of  the  normal  spinal 
cord.  The  markedly  thickened  axis-cylinders  have  no  longer  a  medullary 
layer.  The  medullary  layer  is  destroyed  by  the  thickening  of  the  axis.  Here 
the  relation  is  exactly  the  same  as  it  is  between  cell  and  basis-substance  in  the 
c<  >rnea,  in  cartilage,  and  in  other  tissues.  The  axis-cylinder  of  the  nerve  takes 
the  place  of  the  cell ;  the  medullary  layer  represents  the  basis-substance.  The 
medullary  layer  as  basis-substance  is  distinguished  from  all  other  basis-sub- 
stances in  that  the  meshes  of  the  network  in  the  medullary  layer  are  filled 
with  medullary  substance,  rich  in  fat ;  it  is  distinguished,  furthermore,  in 
that  the  network  of  the  medullary  layer  is  easily  demonstrable  in  fresh  nerves; 
and  finally  in  that  this  network  is  as  firm  and  resistant  as  elastic  tissues,  as 
has  b( m 'ii  shown  by  Kiihne  and  Ewald.  But  this  network  is  firm  and  resistant, 
only  in  a  normal  condition.     In  the  course  of  the  inflammatory  process,  it 

1  Verhanrtl.  d.  naturhist.  mediz.  Veroino,  Heidelbenr,  1S77. 

2  Equivalent  1"  tubular  membrane.     [Note  of  the  Translator.] 


THE   CENTRAL   NERVOUS   SYSTEM.  49 

again  becomes  similar  to  the  embryonic  protoplasm.  During  this  trans- 
formation the  medullary  layer  disappears.  Axis-cylinders  and  network  now 
coalesce,  and  form  one  mass,  which  looks  in  transverse  section  like  a  large 
axis-cylinder.  But  in  longitudinal  sections  we  see  that  the  swellings  are  very 
unequal;  that  marked  intumescences  alternate  with  spots  of  almost  normal 
dimensions.  Hence  the  swollen  axis-cylinder  is  wont  to  look  like  a  knotted 
club.  In  these  swellings  new  nuclei  arise  (as  was  tirst  recognized  by  Dr. 
Hamilton).1  Hence  a  multinucleated  protoplasmic  mass  takes  the  place  of  the 
medullated  nerve.  These  large  nucleated  masses  soon  subdivide  into  smaller 
cells  which  resemble  pus-corpuscles. 

This  process,  however,  does  not  represent  the  ordinary  form  of  suppuration 
of  the  spinal  cord.  When  the  spinal  cord  suppurates,  large  numbers  of  cells 
containing  fat  granules  are  formed.  Now  with  regard  to  these  fat  cells  in 
the  inflamed  spinal  cord,  a  student,  Ernst  Baumler,  has  under  my  supervision 
quite  recently  obtained  very  remarkable  results ;  results  which  throw  a  re- 
markable light  on  the  theory  of  suppuration  as  well  as  on  general  histology. 
The  cells  with  fat  granules  which  occur  in  the  spinal  cord  are  essentially  dif- 
ferent from  such  fat  cells  as  the  colostrum  corpuscles,  and  the  fat  cells  found 
in  the  liver  and  in  other  glandular  organs.  The  fat  cells  of  the  spinal  cord 
are  characterized  in  the  first  place  by  their  very  great  variation  in  size,  and 
by  a  peculiar  appearance  of  the  fat  globules.  But  this  is  a  minor  considera- 
tion. Of  much  greater  importance  are  the  things  which  are  to  be  seen  in  the 
interior  of  these  fat  cells  after  the  extraction  of  the  fat.  Many  of  these  cells 
still  bear  distinct  traces  of  their  genesis.  Their  body  consists  of  a  network  of 
exactly  the  same  kind  as  is  observed  in  the  still  connected  portions  of  the 
spinal  cord  in  the  neighborhood  of  the  suppurative  focus.  Whilst  on  one 
side  of  the  specimen  (that  is,  towards  the  cavity  of  the  abscess),  these  peculiar 
reticulated  cells  are  found  isolated,  in  the  immediate  neighborhood  they  are 
still  connected  together,  though  the  lines  of  partition  are  already  indicated ; 
and  somewhat  further  off  even  these  partition  lines  are  wanting,  though  ex- 
actly the  same  network  is  present  as  in  the  cells.  There  can  no  longer  be 
any  doubt  that  the  entire  mass  of  white  and  gray  matter  has  become  sub- 
divided, in  exactly  the  same  manner  as  has  been  demonstrated  in  the  case  of 
the  cornea  by  staining  with  silver. 

In  the  case  of  the  cornea,  however,  a  flaw,  though  only  a  slight  one,  still 
remained  in  the  argument.  Are  the  cells  in  the  already  completed  abscess- 
cavity  (/.  e.,  the  cells  after  the  destruction  of  the  tissue)  realty  the  same  as  the 
cells  indicated  by  brown  lines  in  the  silver-stained  specimens  of  tissue  not  yet 
broken  down  by  suppuration?  This  is,  in  a  high  degree,  probable;  but  the 
pus-corpuscles  of  the  cornea  contain  no  direct  signs  of  their  genesis.  In  the 
other  case,  however,  the  subdivisions  still  bear  signs  of  their  origin.  In  the 
network  there  remain  probably  the  debris  of  the  very  tatty  medullary  >ul>- 
stance  (really  intermediate  substance).  It  is  presumable,  moreover,  that  the 
tissue  also  produces  new  fat.  For  the  production  of  fat  is  one  of  the  specific 
peculiarities  belonging  to  Various  tissues,  and,  among  others,  to  the  white 
nerve  matter.  However,  let  the  fat  come  whence  it  may;  the  essence  of  the 
affair  is  not  changed  thereby. 

Not  rarely  we  see  also  a  nucleus  in  the  network  of  some  cells,  on  one  of  the 
trabecule.  We  also  find  cells  in  which  the  system  of  trabecule  is  only  partly 
preserved,  the  remainder  already  having  formed  a  homogeneous  mass.  This 
phenomenon  is  entirely  comprehensible.  I  have  proved  by  direct  observa- 
tion2 that  cells  which  expel  their  fat-globules  afterwards  resemble  ordinary 

1  Quarterly  Journal  of  Microsc.  Science,  vol.  xv.,  new  series. 

2  Wiener  Sitzungsberichte,  Bd.  53 ;  2te  Abth. 
VOL.  I. — 4 


50  PATHOLOGY   OF   INFLAMMATION. 

solid  amoeboid  cells.  On  the  other  hand,  we  know  that  in  every  amoeboid 
cell  vacuoles  can  appear  and  disappear.  From  researches  which  have  been 
made  under  my  direction  on  the  genesis  of  nerve-tissue,1  we  know  moreover 
that  embryonal  cells,  while  building  up  the  nerve-tissue,  while  being  trans- 
formed into  tissue  of  the  central  nervous  system,  produce  numerous  small 
vacuoles  within  their  body,  and  thus  are  directly  converted  into  a  network. 
Only  subsequently  is  the  medullary  substance  produced  within  the  network. 
Accordingly,  the  entire  tissue  is  subdivided  during  the  process  of  suppuration 
into  components  analogous  to  those  from  which  it  was  constructed. 

Suppuration  of  the  spinal  cord  is  one  of  the  rarest  occurrences,  unless  as 
the  result  of  injury.  The  chronic  forms  of  inflammation,  however,  are  less 
rare.  Chronic  inflammation  of  the  spinal  cord  is  characterized  in  most  in- 
stances by  the  growth  of  the  network  of  connective  substance.  The  growth 
represents  itself  as  an  increase  in  mass  of  the  various  trabecule  of  the  net- 
work, and  this  increase  in  mass  occurs  at  the  expense  of  the  neighboring 
tissue,  at  the  expense  of  the  adjoining  nerves.  In  the  thickened  trabecule  of 
the  network  of  connective  substance,  we  also  still  see  vestiges  of  the  axis- 
cylinders  ;  vestiges  of  varying  distinctness,  according  to  the  degree  of  meta- 
morphosis which  they  have  already  undergone.  Such  a  condition  is  found  in 
tabes  dorsalis,  in  the  scleroses  of  the  lateral  columns,  in  ordinary  chronic 
myelitis,  in  syphilis,  in  the  myelitis  of  drunkards,2  and  in  other  chronic  forms 
of  disease. 

In  the  severe  and  progressive  forms,  however,  the  change  does  not  cease 
with  this  thickening  of  the  connective  substance.  The  thickened  network  of 
connective  substance,  and  the  inclosed  nerve-fibres,  break  down  into  fibrilla?, 
as  was  first  shown  under  my  supervision  by  Dr.  Nath.  Weiss,  in  a  case  of 
tabes  dorsalis.  The  destruction  takes  place  principally  in  a  direction  parallel 
to  the  longitudinal  axis  of  the  spinal  cord.  In  such  places  we  find  the  white 
matter  of  the  cord  replaced  by  a  fibrillated  tissue.  Here  and  there  the  bun- 
dles of  fibrillre  still  have  the  same  arrangement  as  in  the  normal  tissue.  In  a 
transverse  section  we  still  recognize  the  arrangement  of  axis-cylinders  and 
network ;  but  they  already  consist  of  fibrillar  which  appear  (in  transverse  sec- 
tion) as  small  granules,  but  which  can  be  followed  deeper  down  (in  the  longi- 
tudinal direction)  by  the  aid  of  the  fine  adjustment,  and  are  thus  recognized 
as  sections  of  fibres.  On  one  side,  these  spots  border  on  a  tissue  with  no 
indication  of  a  fibrillar  degeneration,  in  which  we  can  recognize  the  swollen 
network  of  connective  substance  and  the  medullated  nerves,  and  on  the  other 
side  on  a  felt  of  fibrillar,  from  which  every  trace  of  the  former  tissue  has  dis- 
appeared. Here  wre  accordingly  see  again  (just  as  in  the  case  of  the  muscle) 
a  final  result  of  the  chronic  process  which  in  its  consequences  as  regards  the 
function  of  the  part,  is  similar  to  an  acute  suppurative  inflammation.  In  the 
one  case,  as  in  the  other,  the  nerve-tissue,  as  such,  is  destroyed,  and  the  func- 
tion of  the  corresponding  nerve  territory  is  lost  for  ever. 

Hut  from  a  clinical  point  of  view,  the  two  processes  vary  in  the  extent  of 
the  destruction.  An  acute  process  is,  as  a  rule,  limited.  In  this  respect  let 
us  consider  a  cutaneous  abscess  as  typical.  Such  an  abscess,  in  any  particu- 
lar instance,  never  spreads  beyond  its  original  site.  The  infiltration  limits 
itself,  breaks  down  in  the  centre,  and  therewith  the  height  of  the  process  is 
reached.  If  no  new  abscess  is  formed  in  the  neighborhood,  we  may  look  for- 
ward with  some  certainty  to  the  termination  of  the  process.  The  circum- 
stances are  similar  in  regard  to  all  abscesses,  though  the  importance  of  the 

1  See  my  Lectures,  page  508. 

2  F  obtained  a  view  of  the  appearances  in  these  forms  of  disease  through  the  kindness  of  Dr. 
Nathan  Weiss,  who  prepared  the  specimens  in  my  laboratory. 


DISCUSSION   OX   THE   NATURE   OF   THE   FIBRILL.E.  51 

organ,  the  functional  value  of  the  destroyed  portion,  must  be  taken  into  con- 
sideration. Xot  such  is  the  course  in  those  chronic  forms  of  inflammation 
that  lead  to  fibrillar  degeneration.  Judging  from  the  view  now  prevalent 
with  regard  to  tabes  dorsalis,  these  processes  are  terminated  by  death  only. 
Slowly  but  steadily  does  the  transformation,  the  metamorphosis  of  the  tissue, 
proceed,  and  thus  destroy  the  function  of  the  organ.  Hence,  in  their  import- 
ance to  the  organism,  these  chronic  processes  are  to  be  compared  with  malig- 
nant new  formations.  But  we  must  here  note  the  following  considerations: 
As  long  as  the  fibrillar  degeneration  has  not  taken  place,  as  long  as  the 
chronic  inflammation  has  not  passed  beyond  swelling  of  the  network  of  con- 
nective substance,  from  the  histological  standpoint1  a  cure  is  still  conceivable. 
Accordingly,  if  physicians  should  ever  be  enabled  to  arrest  the  progress  of 
the  disease  before  the  fibrillar  degeneration  had  taken  place,  a  complete  cure 
would  still  be  possible.  It  also  appears  certain  to  me  that  absolute  rest,  that 
the  absolute  avoidance  of  functional  hypenemia,  is  one  of  the  means  by  which 
a  return  to  the  normal  condition  in  certain  well-marked  forms  of  myelitis 
may  be  hastened.  But  where  the  fibrillar  degeneiation  has  taken  place  (and 
this  holds  good  for  the  advanced  forms  of  the  disease),  a  return  to  the  normal 
state  is  not  to  be  thought  of.2 

I  shall  now  make  use  of  this  explanation  for  a  further  discussion  of  the 
fibrillar  structure  of  tissues.  The  assertion  that  the  white  matter  of  the 
spinal  cord  was  fibrillar,  in  the  same  sense  as  the  cornea  or  the  tendon,  would 
surely  be  rejected  by  histologists,  and  justly  so.  And  yet,  under  certain 
circumstances,  it  breaks  up  into  fibrillse.  The  objection  may  be  raised  that 
this  only  holds  good  in  the  case  of  disease.  It  may  be  said,  indeed,  that  here 
a  metamorphosis  has  first  taken  place  ;  that  the  entire  tissue  has  first  returned 
to  the  embryonic  condition ;  that  it  has  virtually  become  something  different 
from  what  it  was.  First  it  became  connective  tissue,  and  then  only  did  it 
break  up  into  fibrillar  On  the  other  hand,  however,  we  must  consider  that 
the  line  between  pathological  and  normal  processes  is  drawn  arbitrarily,  and 
only  with  reference  to  the  practical  requirements  of  man.  The  assertion  that 
the  nerve-tissue  which  has  returned  to  the  embryonic  condition  is  now 
become  connective  tissue,  is  also  quite  arbitrary.  True,  the  axis-cylinders 
coalesce  with  the  trabecule  of  connective  substance.  But  these  trabecule 
likewise  have  returned  to  the  embryonic  condition.  Now  who  will  assert 
that  they  are  still  connective  tissue?  And  who  can  claim  that  the  axis- 
cylinders  have  been  converted  into  connective  tissue?  If  we  wish  to  judge 
objectively,  we  must  accept  facts  as  they  appear  to  us.  The  axis-cylinders 
break  up  into  fibrillre ;  this  is  a  fact ;  but  what  the  fibrilla?  are  we  do  not 
know.  But  this  we  know — that  they  are  not  nerves,  and  that  they  no  longer 
perform  the  function  of  nerves. 


¥ew  Observations  on  the  supposed  Fixed  Cells.     Conclusion  of  the 
Discussion  on  the  Nature  of  the  Fibrill.e. 

I  have  already  mentioned  that  immediately  after  excision  of  the  normal 
cornea  we  can  observe  in  it  no  trace  of  structure,  but  that  we  can  render  the 
cornea-corpuscles  visible  by  means  of  various  reagents.  Now  the  circum- 
stance that  this  reaction  appeared  so  regularly — that  after  staining  with  gold, 

1  This  matter  is  discussed  in  my  Lectures,  and  I  shall  treat  of  it  more  in  detail  in  a  separate 
publication. 

2  Perhaps  further  information  in  regard  to  the  etiology  of  these  affections  will  teach  us  that 
the  steadily  progressive  processes  are  dependent  upon  some  constitutional  condition,  such  as  the 
presence  of  syphilis  or  other  infectious  disease.     This  has  already  been  conjectured. 


52  PATHOLOGY   OF   INFLAMMATION. 

for  instance,  the  violet-colored  branched  corpuscles  appeared — made  us  incline 
to  the  belief  that  these  corpuscles  existed  in  the  living  cornea.  Moreover, 
this  conclusion  seemed  to  be  supported  by  the  fact  that  the  branched  corpus- 
cles were  wont  to  appear  with  the  same  configuration — though  isolated — if 
the  normal  fresh  cornea  lay  in  aqueous  humor  several  hours  after  excision ; 
and,  finally,  by  the  fact  that  they  were  visible  in  increased  numbers  imme- 
diately after  the  excision  of  an  inflamed  cornea.  It  did,  indeed,  seem  strange 
to  me  that  in  the  inflamed  cornea  they  appeared  only  here  and  there,  and,  | 
moreover,  that  the  specimens  stained  with  gold  had  a  different  appearance 
in  winter  from  that  which  they  had  in  spring  and  autumn.  If,  as  has  been 
supposed,  the  branched  corpuscles  are  arranged  in  the  living  cornea  exactly 
as  they  are  in  the  specimens  stained  with  gold,  then,  judging  from  the  latter 
specimens,  we  must  admit  that  they  are  differently  formed  in  winter  and  in 
spring.  According  to  this  supposition,  therefore,  the  branched  corpuscles  are 
not  fixed  in  the  sense  that  they  continue  unchanged  during  their  entire 
existence. 

Still  another  circumstance  warns  us  against  drawing  unrestricted  conclu- 
sions as  to  the  state  of  the  living  tissue  from  lifeless  specimens  stained  with 
gold.  If  we  paint  the  cornea  before  excision  with  a  stick  of  nitrate  of  silver 
until  it  has  become  cloudy,  excise  it  about  thirty  minutes  later,  and  then 
expose  it  to  diffused  daylight,  we  obtain  a  picture  which  is  essentially 
different  from  that  obtained  by  staining  with  gold.  In  a  specimen  thus 
treated,  the  processes  of  the  cornea-corpuscles  appear  branched  to  such  a 
degree  that  the  basis-substance  is  traversed  by  an  excessively  rich  network. 
With  a  magnifying  power  of  about  1000  diameters,  the  basis-substance  looks 
like  a  loosely  woven  tissue.  Since  I  had  observed  similar  networks  in  the 
gray  matter  of  the  brain,  and  since,  moreover,  similar  networks  were  known 
to  exist  in  bone,  I  expressed  the  opinion  that  all  organs  were  built  up  of 
such  a  fine  network.  The  network,  added  to  the  mass  which  filled  up  its 
meshes,  formed,  as  I  thought,  the  basis-substance,  whilst  the  cells  were 
nothing  else  than  parts  of  this  network  with  a  different  density,  and  a  dif- 
ferent mass  filling  their  interior.  In  the  cells,  I  thought,  there  is  a  fluid 
{intracellular  fluid),  whilst  the  basis-substance  has  a  mass  in  its  meshes  which 
lends  it  its  characteristic  physical  stamp,  different  in  bone,  different  in  the 
cornea,  different  in  cartilage — in  short,  varying  according  to  the  nature  of 
the  tissue.  But  the  very  marked  ramification  which  we  see  in  cornese 
painted  with  silver,  does  not  appear  in  specimens  stained  with  gold,  though 
here  also  the  ramification  is  at  times  very  extensive.  At  times,  I  say,  but 
not  always.  Accordingly,  the  reagent  must  have  some  influence  on  the  con- 
formation of  the  lifeless  and  fixed  condition ;  the  cornea-corpuscles  and  their 
processes  must  perish  in  varying  shape  in  consequence  of  varying  influences 
Drought  to  bear  on  them. 

Besides,  after  proof  had  been  offered  that  the  cornea-corpuscles  became 
altered  in  consequence  of  an  inflammatory  irritation ;  that  in  the  cornea  of 
the  frog  they  appeared  essentially  altered,  even  a  few  hours  after  the  applica- 
tion of  the  irritant;  that  they  lost  their  processes  here  and  there  and  were 
transformed  into  relatively  large  multi-nucleated  masses;  after  I  had  made, 
moreover,  the  observations  on  the  cornea  of  mammalia  which  led  me  to  adopt 
the  theory  of  inflammation  and  suppuration  already  described — the  theory 
that  the  cells  and  their  processes  swell  at  the  expense  of  the  basis-substance — 
in  view  of  all  these  considerations,  I  had  all  the  more  ground  to  doubt  the 
stability  of  the  supposed  fixed  cells.  And  yet  not  until  quite  recently  have  I 
shaken  the  axiom  that  the  branched  cells  in  the  normal  condition  are  fixed 
cells. 

During  the  past  year,  Dr.  Hansell  has  been  engaged  under  my  direction  in 


DISCUSSION   ON   THE   NATURE   OF   THE   FIBRILL.E.  53 

studying  the  keratitis  of  infection,  and  in  so  doing  has  met  with  very  remark- 
able experiences  in  regard  to  the  processes  taking  place  in  the  cornea  of  the 
rabbit.  It  appeared  that,  while,  on  the  one  hand,  the  network  of  cells  in- 
creased at  the  expense  of  the  basis-substance,  there  were  spots  adjoining  where 
the  cells  disappeared,  and  where  the  basis-substance  increased  in  extent. 
These  spots  seemed  to  correspond  to  a  process  of  healing  and  cicatrization. 
However  the  clinical  signification  of  the  process  is  not  in  question  here.1  The 
fact  that  fixed  cells  are  transformed  in  a  short  time  into  basis-substance,  has 
induced  me  to  take  up  this  question  once  more.  And  thus  I  have  been  led  to 
examine  the  inflamed  cornea  of  the  frog  on  the  heatable  stage,  with  the  result 
of  showing  that  the  branched  cells  are  not  fixed,  at  a  temperature  of  about 
36-38°  C.  [96°.8-100°.4  F.J,  but  that  processes  disappear  and  reappear,  and 
that  the  cells  also  alter  their  entire  configuration. 

In  order  to  make  this  examination  easily,  I  recommend  injuring  the  cornea 
of  the  frog  by  sewing  a  thread  through  its  centre,  one  to  three  days  before 
the  examination,  according  to  the  season  of  the  year,  and  beginning  the  obser- 
vations on  the  unheated  heatable  stage.  As  soon  as  branched  cells  have  been 
found,  begin  to  heat.  At  times  we  hit  upon  branched  corpuscles  that  change 
even  on  the  unheated  stage ;  then  again  upon  others  which  make  only  Blight 
movements  in  spite  of  the  heating ;  then  again  upon  such  as  are  transformed 
under  our  very  eyes  on  the  heatable  stage  into  bodies  without  processes,  re- 
sembling migratory  cells ;  and  finally  upon  such  as  gradually  disappear  from 
view,  or,  in  other  words,  gradually  assume  the  appearance  of  the  basis- 
substance.2 

In  view  of  these  observations,  I  can  no  longer  maintain  the  opinion  that  the 
branched  cells  of  the  cornea  are  fixed.  Moreover,  I  can  no  longer  answer 
with  an  unconditional  "yes,"  the  question  as  to  the  existence  of  branched  cells 
in  the  normal  living  cornea.  I  consider  it  advisable  now  to  regulate  my  state- 
ments rigidly  according  to  the  results  of  observation.  In  the  fresh  cornea,  I 
do  not  see  any  cornea-corpuscles;  therefore  it  is  undetermined  whether  they 
exist  there  at  all.  My  experience  admits  of  the  statement  that  these  corpuscles 
are  formed  under  the  influence  of  inflammation,  or  of  reagents.  A  definitive 
conclusion  on  this  subject  is  reserved  for  the  future.  But  at  all  events  it  is  1 1<  >w 
proved  by  direct  observation  that  under  the  influence  of  the  process  of  inflam- 
mation, basis-substance  is  transformed  into  branched  cells,  and,  conversely^ 
branched  cells  are  converted  into  basis-substance;  and  herewith  my  theory  of 
inflammation  and  suppuration  is  proved  even  to  its  ultimate  consequences. 

In  the  advanced  stages  of  inflammation,  still  other  phenomena  may  be 
observed  on  the  heatable  stage.  Here  and  there  I  have  seen  a  network  as 
fine  as  that  described  above  (page  52),  in  the  case  of  cornea?  painted  with 
silver.  But  the  network  did  not  remain  constant;  it  changed  continually; 
threads  appeared  and  disappeared  again.  In  other  places  again  I  saw  a 
fibrillar  structure,  and  the  fibrillar,  too,  were  not  constant.  At  one  time 
they  would  run  together  at  a  certain  spot,  so  as  to  make  it  appear  that  there 
was  a  cell  inclosed  in  the  bundle  of  fibrillin ;  at  another  time  this  coalesced 
mass  would  divide  into  fibrillse  again. 

On  the  strength  of  these  observations,  I  believe  that  I  can  now  give  a 
decisive  answer  to  the  question  as  to  the  nature  and  the  import  of  the  fibrilla?. 
As  soon  as  I  know  that  fibrillar  can  appear  and  disappear  again  in  the  cornea 

1  Dr.  Hiinsell  will  treat,  of  this  in  a  separate  article. 

2  These  observations  were  made  by  me  during  the  last  weeks,  just  as  the  manuscript  of  this 
article  was  receiving  its  last  corrections.  I  consider  my  observations  thoroughly  reliable,  and 
for  this  reason  publish  them.  But  I  am  not  quite  sure  of  one  thing  ;  I  do  nut  know  bow  soon  the 
changes  of  the  fixed  corpuscles  cease.  These  changes  I  saw  with  certainty  (during  the  days  from 
the  1st  to  the  20th  of  October,  1880),  only  about  15  or  20  minutes  after  excision. 


54  PATHOLOGY    OF   INFLAMMATION. 

under  our  very  eyes,  then  there  is  no  longer  ground  for  the  assumption  that 
the  cornea  is  fibrillar  in  the  living  state.  I  can  now  support  my  opinion  by 
observation,  which  teaches  that  in  life  the  normal  cornea  is  not  fibrillar,  but 
homogeneous,  and  that  in  certain  pathological  conditions,  or  before  death,  it 
becomes  fibrillar.  Whoever  now  still  asserts  that  the  cornea  or  the  cords  of 
connective  substance  are  constructed  of  fibrillar,  must  prove  his  assertion. 

In  accordance  with  these  explanations,  I  consider  it  advisable  to  separate 
distinctly  the  expressions  fibrillar  and  connective-tissue-like  (bindegewebig). 
A  tissue  which  appears  fibrillar  to  us,  is  not  necessarily  connective  tissue. 
Hence  it  is  also  desirable  to  retain  in  pathology  the  plain  term  "  fibrillar."  If 
therefore  the  spinal  cord  is  transformed  into  fibrillar,  we  shall  designate  this 
as  a  fibrillar  degeneration,  or  as  a  formation  of  fibrillar  tissue.  If  the  con- 
nective substance  in  the  spinal  cord  is  increased,  this  has  by  no  means  the  same 
signification  as  fibrillar  degeneration.  Wherever  the  tissue  has  once  defi- 
nitively degenerated  into  fibrillse,  its  function  is  forever  destroyed.  Swelling 
of  the  reticulated  tissue  of  the  white  matter  does  not,  however,  exclude  the 
possibility  of  a  cure,  as  I  have  already  remarked.  This  swelling — although, 
according  to  our  present  nomenclature,  we  call  it  proliferation  of  connective 
substance — is  equal  in  significance  to  infiltration.  The  infiltration  can 
degenerate,  while  the  fibrillar  on  the  other  hand  are  products  of  degeneration.1 

All  that  I  have  said  here  in  regard  to  fibrillar,  only  refers  to  their  occurrence 
in  bundles.  But  there  are  tissues  which  contain  fine  isolated  fibrillar.  Such 
fibrillse  may  occur  sparsely  or  abundantly.  But  each  one  takes  its  own 
direction,  and  where  they  occur  abundantly  they  may  even  form  a  felt  (Filz) 
of  intersecting  threads.  The  nature  of  all  of  these  threads  is  by  no  means  a 
settled  question.  At  times  they  are  processes  of  smooth  muscular  fibres,  as 
e.  g.  many  of  the  fibrillar  in  the  bladder  of  the  frog ;  at  times  processes  of 
transversely  striped  muscular  fibres,  as  for  example  in  the  auricles  of  the 
frog ;  at  times  they  are  nerves,  such  as  likewise  occur  in  the  bladder  of  the 
frog;  at  times  again  elastic  fibres,  ?'.  e.  cell-processes  which  have  become 
resistant ;  finally  they  are  very  thin  bundles  of  connective  tissue  (as  e.  g.  in 
the  interstices  of  the  frog's  muscle),  which  form  a  felt  and  may  be  designated 
as  fibrillse.  These  are  indeed  not  very  fine  fibrillar,  but,  as  already  remarked, 
very  thin  cords,  which  are  commonly  called  (and  perhaps  justly)  connective 
tissue,  because  of  their  wavy  appearance  and  because  of  their  reaction 
(becoming  swollen)  with  acetic  acid. 

From  the  results  of  my  most  recent  investigations,  I  no  longer  admit  that 
the  very  fine  networks  which  I  have  demonstrated  in  the  cornea  by  treating 
it  with  lunar  caustic,  are  present  in  the  living  state.  Now,  this  matter  of  the 
reticular  structure  is  a  peculiar  one.  The  living  matter  is  nowhere  chemically 
the  same,  whether  in  the  cells  or  in  the  basis-substances.  In  both  there  are 
always  mixtures.  Besides  the  living  matter,  the  cells  contain  a  fluid ;  the 
basis-substance  of  bone  contains  in  addition  certain  lime  salts;  and  cartilage, 
probably  some  other  substance  which  gives  to  it  its  peculiar  appearance.  Now 
when  I  mix  a  soft  mass  such  as  dough,  with  something  else,  such  as  shot,  the 
doughy  mass  must  contain  pores  in  which  the  foreign  particles  are  situated. 
A  mass  which  has  many  such  pores  must  be  constructed  like  a  network. 
Whether  just  these  are  the  nets  which  I  make  apparent  with  silver,  or  whether 
there"  arc  others  that  only  assume  a  new  configuration  after  the  use  of  the 
silver,  is  not  a  question  of  material  importance.     However,  the  transformation 

1  I  draw  tliti  reader's  attention  here  to  the  fact  that  the  term  "connective  substance"  is  not 
yel  sharply  defined.  I  consider  it  possible  that  the  connective  substance  of  the  nervous  system 
represents  only  an  undeveloped  state  of  nerve-tissne,  from  which  new  nerve-tissue  can  be  de- 
veloped under  favorable  circumstances.  I  shall  treatof  this  more  in  detail  in  the  article  already 
referred  to  on  page  51. 


EPITHELIUM    AND    ENDOTHELIUM.  55 

already  described  of  the  white  blood-corpuscle  into  a  body  resembling  a  sali- 
vary corpuscle,  teaches  us  how  rapidly  such  metamorphoses  take  place  within 
the  living  matter.  I  must  observe  here  that  Heitzmann  was  the  first  to 
describe  the  net-like  structure  of  the  living  matter,  and  to  represent  it  schema- 
tically.1 In  principle  Heitzmann  is  right,  but  practically  I  consider  it  unjusti- 
fiable, now  as  then,  to  conclude  from  the  aspect  of  a  network  in  certain  spots 
of  the  stained  basis-substance  that  this  network  was  there  in  the  living  state. 
I  also  do  not  consider  it  admissible  to  conclude  that  because  I  can  recognize  a 
network  in  a  living  cell,  all  cells  must  have  just  such  networks.  I  must 
moreover  mention  here  that  Kassowitz  was  the  first  to  regard  the  basis-sub- 
stance  of  the  cartilage  in  its  entirety  as  living  matter,2  altogether  without 
reference  to  the  recognition  of  a  reticulated  structure. 


Epithelium  and  Endothelium. 

Only  two  types  of  tissue  still  remain  to  be  spoken  of:  Endothelium  and 
Epithelium.  The  lining  cells  of  serous  membranes  we  call  endothelium  ;  that 
is,  the  lining  cells  of  the  peritoneum,  of  the  pleura,  and  of  the  pericardium. 
We  may  also  include  here  the  intima  of  vessels.  In  all  of  these  endothelial 
cells  (as  has  already  been  described  in  detail),  we  can  make  the  boundaries  of 
certain  nucleated  fields  apparent  as  brown  lines,  by  using  solutions  of  silver. 
These  brown  lines  are  called  cement-substances  (Kittsubstanzen)  and  cement- 
lines  (Kittstreifen).  As  I  have  likewise  already  remarked,  we  may  place  the 
cement-substance  on  a  par  with  the  basis-substances.  We  know  but  little  of 
the  normal  function  of  the  endothelial  cells.  We  know  that  the  surface  of 
serous  membranes  is  moist,  and  we  suspect  that  the  endothelium  plays  a  part 
here.  Furthermore,  on  the  basis  of  experiments  by  E.  Briicke,3  we  suspect 
that  the  endothelium  of  the  vessels  assists  in  keeping  the  blood  fluid.  On  the 
other  hand,  on  the  basis  of  experiments  which  Durante4  has  performed  under 
my  direction,  I  suspect  that  in  consequence  of  disease  of  the  endothelium  of 
vessels  after  ligation,  the  coagulation  of  the  blood  in  the  neighborhood  of  the 
ligature  is  promoted.  It  has  furthermore  been  supposed  that  the  endothe- 
lium of  the  serous  membranes  served  the  purpose  of  absorption.  However, 
we  know  now  that  the  stomata  discovered  by  Recklinghausen  in  the  serous 
membranes,  lead  directly  into  the  lymphatics  by  means  of  canals,  and  bring 
about  absorption. 

Endothelium  has  been  most  accurately  investigated  by  E.  Klein,5  who  has 
shown  that  single  groups  of  endothelial  cells  proliferate  even  in  the  normal 
condition,  besides  doing  so  in  a  state  of  inflammation.  As  a  result  of  inflam- 
matory irritation,  the  endothelial  cells  of  the  bloodvessels  as  well  as  of  the 
serous  membranes  return  to  their  embryonic  condition ;  they  become  softer 
again  and  more  permeable ;  they  swell,  and  their  nuclei  multiply.  In  this 
way  suppuration  of  the  endothelium  takes  place  in  serous  membranes.  The 
serous  membrane  is  deprived  of  its  endothelium.  The  pus-corpuscles  fall  into 
the  serous  sac,  and  appear  there  in  the  so-called  exudation  as  pus-cor- 
puscles. Whether  and  how  capillaries  suppurate,  I  know  not.  But  there  is 
not  the  slightest  doubt  that  the  intima  of  arteries  and  veins  can  suppurate. 
In  chronic  inflammations,  the  endothelial  cells  grow ;  they  are  prolonged  so 
as  to  form  cords,  wdiich  resemble  cords  of  connective  tissue.  The  cords  of 
tissue  produced  from  the  endothelium,  form  the  so-called  false  membranes. 

'  Wiener  Sitzungsberichte,  1873,  Bd.  67  ;  3te  Abth.  2  Wiener  mediz.  Jahrb.  1879-1880. 

8  Virchow's  Archiv,  N.  F.,  Bd.  xii.  *  Med.  Jahrbiiclier,  1872,  S.  143. 

5  Anatomy  of  the  Lymphatic  System.     Loudon,  1875. 


56  PATHOLOGY   OF   INFLAMMATION. 

They  cause  the  firm  adhesion  of  the  serous  membranes,  whence  is  derived  the 
name  adhesive  inflammation  (John  Hunter). 

The  fact  that  the  capillaries  send  out  offshoots  and  thus  produce  a  new 
vascularization,  I  have  already  mentioned. 

Epithelial  Cells  are  likewise  separated,  or  rather  united,  by  narrow  strips  of 
intermediate  substance.  Here,  too,  brown  boundary  lines  become  visible  by 
staining  with  silver.  On  many  epithelial  cells  (cornea,  cutis,  and  others),  fine 
threads  have  been  observed  {Prickle  cells,  Max  Schultze1),  which  are  connect- 
ing threads  between  two  neighboring  cells,  as  has  been  shown  by  Bizzozero.2 
Accordingly,  epithelium  constitutes  a  tissue  similar  to  the  connective  sub- 
stances with  this  exception,  that  the  amount  and  structure  of  the  basis-sub- 
stances, and  naturally  also  the  form  and  function  of  the  cells,  are  different. 

The  functions  of  the  epithelial  cells  are  extraordinarily  varied.  In  the 
glands,  the  main  task  of  secretion  falls  to  their  lot.  They  must  therefore  be 
adapted  to  the  multifarious  actions  of  the  various  glands.  The  part  which  is 
played  here  by  the  mechanical  action  (enlargement  and  diminution)  of  the  cells, 
I  have  already  heretofore  described.  In  the  intestine,  the  epithelial  cells  are 
certainly  concerned  in  the  process  of  absorption.  Spina  is  about  to  publish 
an  article  in  which  he  shows  that  in  this  process  also,  the  mechanical  action 
of  the  cells  (swelling  and  subsequent  diminution)  comes  into  play.  But  of 
the  function  of  by  far  the  greater  portion  of  epithelial  cells,  those  of  the  cutis, 
the  intestine,  the  air-passages,  and  the  urinary  organs,  we  know  very  little. 
In  general,  it  is  said  that  they  serve  as  a  cover,  as  a  protective  lining,  and 
are  present  on  the  mucous  membranes  for  the  production  of  mucus  to  keep 
the  surface  viscid.  The  ciliated  epithelium  is  believed  to  serve  for  the  removal 
of  fine  particles.     But  these  statements  are  surely  not  exhaustive. 

The  pathological  processes  in  the  epithelium  of  certain  organs  are  better 
understood.  Slight  stimuli  suffice  to  excite  a  secretion  of  mucus  in  certain 
epithelial  cells,  though  it  is  certain  that  the  vascular  system  co-operates  here. 
Acute  catarrhal  processes,  when  they  appear  in  otherwise  normal  mucous 
membranes,  commence,  as  a  rule,  with  a  profuse,  watery  transudation,  and 
only  at  a  later  period  does  the  secretion  of  mucus  begin.  The  profuse  watery 
transudations  surely  come  from  the  blood,  and  even  the  mucus  must  partly 
come  from  the  same  source,  inasmuch  as  we  may  assume  that  the  cells  must 
draw  fresh  (fluid)  material  from  the  blood  in  order  to  secrete  as  "profusely  as 
they  are  wont  to  do  in  catarrhal  processes.  But  the  conversion  into  mucus  of 
the  material  drawn  from  the  blood,  must  certainly  be  performed  by  the 
epithelium.  During  this  conversion,  the  cells  are  abnormally  active,  and  as 
a  rule  we  have  cell-proliferation  accompanying  the  process.  As  a  general 
thing,  also,  we  find  single  amoeboid  cells  which  are  called  mucus-corpuscles 
from  the  locality  in  which  they  occur.  If  the  production  of  cells  increases, 
the  mucus  is  gradually  changed  into  pus.  But  there  are  intermediate  stages, 
in  which  indeed  there  are  already  produced  very  many  amoeboid  cells,  but  in 
which  there  is  also  still  a  production  of  mucus.  Finally,  the  production  of 
mucus  may  cease  entirely,  and  pus  alone  make  its  appearance.  But  then  we 
may  presume  that  the  epithelium  as  such  has  been  destroyed,  and  that 
embryonic  proliferating  cells  have  taken  its  place,  or,  in  other  words,  that  the 
epithelium  lias  returned  to  its  embryonic  condition. 

In  the  case  of  epithelium,  this  return  frequently  takes  place  in  a  central 
portion  of  the  cell,  when  the  peripheral  portion  of  its  body  remains  rigid  and 
sterile.  This  species  of  cell  multiplication  is  termed  endogenous.  It  was 
firsl  observed  by  Remak  in  the  epithelium  of  the  urethra,  in  gonorrhoea. 
As  is  seen,<  ndogenesis  is  nothing  else  than  a  cell  formation  by  division.     Only 

»  Medic.  Centralblatt,  1864.  «  Medic.  Centralblatt,  1871,  S.  482. 


HEALING    BY    FIKST    INTENTION    AND    HEALING    BY    GRANULATION.  57 

here  a  central  portion  of  the  cell  divides.  The  peripheral  portion  of  the 
body  forms  a  hull,  a  capsule,  a  matrix  in  which  young  cells  lie.  But  the 
young  cells  are  nothing  else  than  portions  of  the  old  body  which  have  become 
amoeboid.  The  capsule  bursts,  and  the  young  cell  or  the  several  young  cells 
which  were  in  it,  are  liberated  and  appear  on  the  surface  as  pus-corpuscles. 
But  I  must  state  here  that  endogenesis  does  not  always  take  place  in  an  old 
resistant  capsule.  I  would  recall  the  fact  that,  in  the  embryo,  blood-c<  >rpuscl<  ss 
are  produced  by  endogenesis.  And  here  the  capsule  is  still  a  young  cell-body, 
and  even  will  become  a  contractile  vascular  wall,  as  has  already  been  shown. 
Finally  I  wish  to  remark  that  epithelium  does  not  always  reproduce  itself  by 
endogenesis.  I  have  already  seen,  sufficiently  often,  examples  of  complete 
division  in  epithelial  cells,  and  believe  therefore  that  they  can  return  wholly 
to  the  embryonic  condition,  and  undergo  total  division.  The  difference 
probably  depends  on  the  condition  of  the  peripheral  zones.  If  these  are  very 
resistant,  as  appears  to  be  the  case  in  cells  situated  superficially,  then  endo- 
genesis prevails.  The  most  superficial  layers  of  epidermis  seem  to  be  inca]  a  1  >le 
of  proliferation.  Here  the  life  of  the  cells  seems  to  have  reached  too  low  a 
grade,  if  it  be  not  entirely  extinguished.  But  the  next  deeper  layers  of  cells 
show  a  multiplication  of  nuclei  in  conditions  of  irritation.  The  principal 
proliferation  (new  cell-formation)  certainly  takes  place  in  the  deeper  layers  of 
cells  in  the  so-called  rete  Malpighii. 

If  the  suppuration  of  mucous  membrane  has  proceeded  so  far  as  to  finally 
lay  bare  the  substantia  propria,  and  the  pus  is  now  produced  on  this  part, 
we  call  the  diseased  surface  an  ulcer.  As  long  as  the  epithelium  is  preserved, 
the  superficial  inflammatory  process  of  the  mucous  membrane  may  still  lie 
called  catarrh,  although  to  do  so  is  not  quite  correct.  In  a  strict  sense, 
catarrh  is  present  only  as  long  as  the  secretion  consists  of  mucus.  If  the 
(former)  mucous  membrane  produces  pus  only,  it  is  no  longer  a  mucous 
membrane,  and  can  no  longer  be  in  a  catarrhal  state.  We  are  not  so  par- 
ticular, however,  about  fixing  the  limits,  because  frequently  we  cannot  at  all 
decide  whether  the  secretion  is  entirely  devoid  of  mucus  and  consists  only  of 
pus.  It  is  therefore  preferable  to  regard  the  condition  of  the  mucous  mem- 
brane as  the  determining  point,  and  to  draw  the  line  between  catarrh  and 
ulceration  by  using  anatomical  data  as  the  basis  of  our  judgment.  The 
expression  catarrhal  ulcer,  employed  by  pathological  anatomists,  naturally 
only  points  to  the  genesis  of  the  ulcer.  A  catarrhal  ulcer  is  one  which  is  the 
result  of  the  catarrhal  process.  But  one  and  the  same  spot  cannot  be  the  seat 
of  catarrhal  and  ulcerative  processes  at  the  same  time. 


Healing  by  First  Intention  and  Healing  by  Granulation. 

Ulcers  as  well  as  cavities  of  abscesses  heal  by  the  formation  of  granula- 
tions. We  call  the  new  formations  "granulations,"  because  of  the  little  warts 
or  protuberances  on  the  surface  of  the  ulcer  and  the  interior  of  the  abscess- 
cavity  respectively.  "Why  these  new  formations  appear  here  in  the  form  of 
little  protuberances  is  not  known.  These  little  protuberances  consist  of  cells 
which  are  designated  as  granulation  cells.  But  between  the  cell-  we  find 
layers  of  intermediate  substance — now  broader,  now  narrower.  The  cells, 
added, to  the  intermediate  substance,  form  a  young  tissue  from  which  the 
cicatrix  is  produced.  The  matrix  for  this  young  tissue  is  in  the  bottom  of 
the  ulcer  and  in  the  lining  of  the  abscess-cavity  respectively.  The  granu- 
lations are  not  developed  from  the  normal  tissue,  however,  but  from  the 
tissue  infiltrated  by  inflammation.  We  know,  now,  what  the  word  infil- 
tration sio-nifies.     We  know  that  infiltration  consists  of  a  swelling  of  the 


58  PATHOLOGY   OF   INFLAMMATION. 

network  of  cells,  produced  at  the  expense  of  the  basis-substance.  This 
swelling  means  the  extension  of  the  cell-borders — a  conversion  of  basis- 
substance  into  cell-body.  At  the  same  time  the  cells  themselves  become 
capable  of  proliferation.  They  divide,  and  form  pus,  as  long  as  the  process 
is  an  acute  (stiirmisch)  one.  Finally,  a  portion  of  the  infiltrated  tissue  is 
disintegrated.  The  process  becomes  less  intense.  The  disintegration  stops, 
but  the  growth  of  the  cells  continues.  New  boundary  lines  are  also  formed, 
but  the  cells  do  not  separate.  At  the  boundary  lines  intermediate  substances 
appear,  and  herewith  the  genesis  of  tissue  is  begun. 

Suppuration,  however,  does  not  cease  upon  the  commencement  of  tissue- 
genesis.  On  the  most  superficial  layers  of  the  new  tissue  a  real  cell-partition 
still  takes  place,  and  pus  is  formed.  A  moderate  production  of  pus  on  the 
surface  of  the  ulcer  is,  as  physicians  know,  not  at  all  an  impediment  to 
recovery.  But  the  suppuration  must  not  become  so  profuse  as  to  make  the 
newly-formed  tissue  disintegrate ;  for  in  that  case  a  replacement  of  the 
destroyed  tissue  could  not  take  place.  In  recent,  carefully-nursed  wounds 
following  operations,  tissue-genesis  predominates  over  suppuration.  If  the 
process  be  hastened  by  warm  applications,  we  increase  the  suppuration,  indeed, 
but  we  also  hasten  the  replacement  of  the  lost  tissue,  which  could  not  take 
place  were  the  suppuration  to  predominate.  In  old,  badly-treated  ulcers, 
suppuration  and  tissue-genesis  are  about  evenly  balanced,  or  suppuration  even 
may  predominate.  In  such  cases  the  ulcer  does  not  heal,  or  may  even  extend 
more  deeply.  In  other  instances,  again,  the  tissue-genesis  predominates  to 
such  an  extent  that  the  granulations  grow  beyond  the  level  of  the  normal 
surface,  as  "proud  flesh"  Finally,  in  other  cases,  cell-growth  in  general  is 
but  slightly  stimulated,  and  here  also  the  ulcer  does  not  heal,  even  though  it 
does  not  suppurate.  In  this  last  instance,  too,  warm  poultices  can  stimulate 
growth. 

It  is  probable  that  the  varied  course  of  the  healing  process  depends  at  least 
in  part  on  the  fulness  of  the  vessels.  New  vessels  grow  along  with  the 
tissue-genesis.  The  new  tissue,  as  it  is  said,  becomes  vascularized.  I  am 
unable  to  say  anything  on  the  mode  of  this  new  formation.  Statements  in 
reference  to  it  are  indeed  not  wranting ;  but  they  are  based  on  such  faulty 
microscopical  examinations  that  I  do  not  consider  it  worth  while  to  take 
notice  of  them.  It  is  not  likely  that  bloodvessels  are  produced  in  granu- 
lations otherwise  than  in  the  embryo,  and  in  certain  inflammatory  and  non- 
inflammatory new  growths,  in  which  their  genesis  has  been  accurately 
determined  (see  pp.  7  ct  scq.).  That  the  vessels  of  granulation  tissue  consist 
of  young,  soft,  easily  permeable  and  easily  lacerated  tissue,  may  be  inferred 
from  the  circumstance  that  granulating  surfaces  bleed  on  the  slightest  pro- 
vocation. 

The  definitive  cure  of  an  ulcer  cannot  result  from  the  granulations  alone. 
A  covering  of  epithelium  must  be  developed.  This  covering  proceeds  either 
from  the  margins,  that  is,  from  the  place  where  the  epithelium  is  preserved, 
or  from  the  bottom  of  the  ulcer,  if  there  are  glands  still  preserved  there. 
Finally,  the  covering  may  be  artificially  produced1  from  transplanted  pieces 
of  cutis.  It  is  self-evident  that  the  transplanted  portion  must  still  be  covered 
with  cells  of  the  rete,  for  the  protection  of  which,  moreover,  the  uppermost 
cells  are  also  necessary.  From  a  theoretical  point  of  view,  the  transplantation 
of  rete  and  epidermis  ought  in  every  respect  to  be  sufficient  to  furnish  a  new 
centre  for  Hie  production  of  a  new  covering  of  cells  in  the  ulcer,  and  this  has 
in  fact  been  confirmed  by  experiment.     But  whether  it  is  desirable  in  prac- 

1  As  first  practised  by  Reverdin.  See  Gazette  Medieale  de  Paris,  1866,  No.  26.  Report  of 
Marc  See. 


REGENERATION.  59 

tice  to  transplant  only  epidermis  cells  in  place  of  the  entire  cutis,  I  do  not 
know.  The  rationale  of  transplantation  is  to  be  found  in  the  fact  that  epi- 
dermis is  more  readily  developed  from  epidermis  than  from  the  granulation 
tissue  which  arises  from  connective  tissue.  Hence,  if  the  ulcer  be  very  large; 
if  the  pushing  forward  of  epidermis  from  the  margins  have  become  insuffi- 
cient ;  we  transplant  epidermis  to  the  central  portions  of  the  ulcer  in  order  to 
furnish  new  starting  points  from  which  the  healing  process  can  spread. 

Healing  by  the  formation  of  granulation  tissue  is  also  called  healing  by  sup- 
puration, or  by  second  intention,  in  contradistinction  to  healing  by  first  intention 
(John  Hunter).  In  the  process  of  healing  by  first  intention,  there  is  no  sup- 
puration; the  margins  and  surfaces  of  the  wound  unite  directly.  Notwith- 
standing this,  however,  the  old  tissue  must  soften  again,  and  become  capable 
of  growth,  else  a  definitive  union  would  never  occur.  Investigation  has  also 
taught  that  new  processes  are  sent  out  by  the  cells  from  one  surface  of  the 
wound  into  the  other;  and,  besides,  that  in  the  very  small  space  between  the 
surfaces  of  the  wound  there  are  young  cells  to  be  found.  Accordingly,  from 
a  theoretical  standpoint,  the  difference  between  healing  by  first  intention  and 
second  intention  is  only  quantitative.  From  a  practical  point  of  view,  the 
matter  is  indeed  different.  For  in  healing  by  first  intention  the  loss  of  sub- 
stance is  almost  imperceptible,  and  the  wounded  organ  need,  therefore,  suffer 
no  disturbance  of  function  worth  mentioning.  But  healing  by  suppuration 
always  presupposes  a  loss  of  substance,  and  the  tissue  which  replaces  the  old 
one  is  of  a  new  kind,  is  different;  is  cicatricial  tissue,  and  cannot  assume 
entirely  the  function  of  the  former  one.  In  the  cutis,  it  is  true,  the  replace- 
ment of  certain  small  regions  by  cicatricial  formations  is  of  slight  import- 
ance; but  in  the  cornea,  for  example,  if  suppuration  have  occurred,  the  loss 
is  irreparable.  For  cicatricial  tissue  is  not  cornea  tissue ;  cords,  fibrillre,  and 
cells,  are  indeed  present  in  cicatricial  tissue,  but  not  that  homogeneous  mass 
which  I  have  described  as  existing  in  the  cornea. 


Regeneration. 

A  real  regeneration  as  regards  form  and  function,  is  known  to  us  (in  man 
and  mammalia)  only  in  the  case  of  nerves  and  muscle.1  Divided  nerves  heal 
under  favorable  circumstances  in  such  a  manner  as  to  completely  restore  the 
connection  between  the  central  nervous  system  and  the  periphery.  In  view 
of  new  researches  made  by  Jul.  Wagner2  on  this  subject,  I  must  pronounce 
the  older  statements  on  nerve-regeneration  inaccurate.  Regeneration  of  the 
nerves  depends  on  a  chronic  inflammation.  The  medullary  layer  disappears. 
Axis-cylinder,  network  of  the  medullary  layer,  and  Schwann's  sheath,  are 
converted  into  new  morphological  elements.  This  change  occurs  in  the  cen- 
tral as  well  as  in  the  peripheral  extremity.  By  the  growing  together  of  these 
new  morphological  elements  (just  as  in  healing  by  first  intention),  new  nerve- 
tissue  originates. 

The  regeneration  of  nerves  gives  us  probable  proof  that  tissue-genesis  can 
be  influenced  by  the  central  nervous  system.  For  a  return  to  the  normal 
condition,  as  it  occurs  in  the  case  of  a  nerve,  proceeds  apparently  only  under 
the  influence  of  the  central  nervous  system.  If  the  union  of  the  two  extremi- 
ties be  prevented  by  the  excision  of  a  sufficiently  large  piece,  then  it  is  pre- 
sumed that  the  formation  of  new  nerve-tissue  in  the  peripheral  extremity 

1  I  do  not  dwell  farther  on  the  regeneration  of  muscles.  It  is  only  a  matter  of  the  develop- 
ment of  the  old  fibres. 

2  Not  separately  published  by  him ;  I  have  reported  thereon  in  my  Lectures. 


GO  PATHOLOGY   OF   INFLAMMATION. 

will  also  be  prevented.  Positive  and  unequivocal  proof  that  the  growth  and 
nutrition  of  tissues  in  general  are  influenced  by  the  central  nervous  system, 
has,  however,  not  as  yet  been  furnished.  We  are,  it  is  true,  acquainted  with 
affections  of  tissues  which  are  due  to  diseases  of  the  central  nervous  system ; 
such  are  acute  bedsores  in  certain  severe  central  diseases,  and  progressive 
muscular  atrophy  in  connection  with  disease  of  the  ganglia  in  the  ante- 
rior horns  of  the  spinal  cord  (Lockhart  Clarke,  Charcot).  Recently,  Ad. 
Jarisch1  has  discovered  a  very  important  relation  between  diseases  of  the  skin 
and  diseases  of  the  spinal  cord,  likewise  in  the  region  of  the  anterior  horns ; 
the  affection  in  one  instance  was  a  case  of  herpes  iris,  and  in  another  a  case  of 
pemphigus,  though  in  this  the  relationship  was  less  pronounced.  I  have 
carefully  examined  the  specimens  in  question.  The  disease  of  the  anterior 
horns  of  the  spinal  cord  was  quite  evident.  These  data,  it  appears  to  me, 
are  very  important  for  pathology.  But  whether  we  have  to  deal  with  cen- 
tres which  directly  influence  the  tissues — that  is,  with  so-called  trophic 
nerves — or  with  vaso-motor  centres,  is  not  known.  Disease  of  the  vaso-motor 
centres  is  certainly  adapted  to  provoke  pathological  disturbances  in  periphe- 
ral organs,  i.  e.,  in  the  region  of  distribution  of  the  affected  nerves. 


Non-inflammatory  New  Formations. 

All  tissue-changes  which  are  accompanied  by  active  hyperemia,  that  is  by 
the  clinical  phenomena  of  inflammation,  can  also  run  their  course  without 
hyperemia.  Under  such  circumstances,  we  call  the  tissue-metamorphosis  a 
neoplasm.  Since  such  neoplasms  in  the  majority  of  cases  appear  in  the  form 
of  tumors,  they  are  also  simply  called  tumors.  Inasmuch  as  it  was  imagined 
that  these  new  formations  were  in  idea  and  in  structure  foreign  to  the  human 
organism,  and  not  characteristic  of  it,  they  have  been  also  called  spurious  forma- 
tions or  pseudoplasms.  From  the  fact  taught  by  clinical  experience,  that  some 
of  these  new  formations  are  more  or  less  injurious  to  the  organism,  they  have 
also  been  divided  into  benign  and  malignant.  On  the  other  hand,  they  have 
also  been  classified  according  to  form,  consistence,  location,  genesis,  structure, 
and  I  know  not  what  other  principles.  The  scientific  value  of  such  a  classi- 
fication is  very  slight.  In  modern  times  it  has  degenerated  wholly  into 
child's  play.  It  does  not  seem  to  me  worth  while  to  refer  here  to  the  litera- 
ture of  the  subject,  while  we  are  considering  general  questions.  Neoplasms 
[non-inflammatory  new  formations]  are  much  richer  as  regards  forms  of  tis- 
sue than  are  inflammatory  new  formations.  True,  we  have  here  again  only 
cells  and  basis-substances  which  constitute  the  new  formation;  but  the  size 
and  form  of  the  cells,  as  well  as  their  mutual  connection  with  and  relation  to 
the  basis-substance,  are  more  varied.  Moreover,  the  pathological  non-inflam- 
matory new  formation  can  imitate  every  form  of  normal  tissue,  which  never 
happens  in  the  case  of  inflammatory  new  formations.  In  inflammation,  pus, 
fibrillar  tissue,  cicatricial  (issue,  and  epidermis,  can  be  produced;  and,  more- 
over, a  regeneration  can  proceed  from  a  fixed  matrix,  as  in  the  case  of  nerves 
and  muscles.  Neoplasms,  on  the  contrary,  can  imitate  all  forms  of  normal 
tissue  without  proceeding  from  a  matrix  of  the  same  kind.  In  the  midst  of 
connective  tissue,  or  of  muscle,  epithelium  cells  and  even  fully  developed 
glandular  tubes  '-.'in  be  produced.  In  ovarian  cysts,  teeth  and  hairs  may  be 
developed.  In  the  case  of  inflammatory,  as  well  as  of  non-inflammatory,  new 
formations,  (lie  tissues  return  to  their  embryonic  condition,  in  which  they  are 
capable  of  proliferation.     In  non-inflammatory  new  formations,  however,  the 

1  Sitzungsber.  der  Wiener  Akad.  1880. 


DEGENERATION   OF   THE   TISSUES.  61 

impulses  to  growth,  even  if  not  always  more  powerful,  still  appear  to  be  more 
lasting  and  more  varied  than  in  inflammation.  Are  these  impulses  perhaps 
dependent  on  residues  of  intra-uterine  life?  on  residues  that  were  latent,  and 
now  have  become  active  from  some  favorable  circumstance?  are  they  perhaps 
due  to  particles  carried  away  by  the  blood  or  lymph  stream,  which  adhere 
somewhere,  and,  as  it  were,  infect  the  tissue?  Finally,  is  it  perhaps  the  general 
condition  of  the  fluids  which  favors  the  new  formations?  These  are  all 
questions  which  have  until  now  only  been  speculated  upon. 


Degeneration  of  the  Tissues. 

Fatty  Degeneration  of  tissue  can  be  brought  about  in  two  ways: — 

(1)  In  certain  cells  fat  is  developed,  and  collects  to  form  a  drop.  This  drop 
of  fat  presses  the  cell-body  towards  the  periphery ;  of  the  body,  only  a  peripheral 
zone,  surrounding  the  drop  and  also  containing  the  nucleus,  remains.  The 
normal  prototype  of  this  form  of  degeneration  is  shown  in  the  collections  of 
fat  in  the  subcutaneous  tissue,  and  in  other  normal  deposits  of  fat.1  Patho- 
logical types  of  fatty  tissue  are  presented  in  the  case  of  the  lipoma,  and  in  the 
excessive  development  of  fatty  tissue  in  normal  localities. 

(2)  The  normal  type  of  the  second  form  of  development  of  fat  presents  itself 
in  the. epithelium  of  the  mammary  glands.  Here  the  fat  is  deposited  in  the 
form  of  granules,  or  little  drops,  which,  relatively  to  the  cell,  are  very  small. 
The  entire  cell,  at  every  depth,  appears  tilled  with  granules.  During  the 
first  days  of  lactation,  portions  of  the  cells  containing  fat-granules  separate 
from  their  matrix,  and  are  expelled  with  the  milk.  Such  bodies  are  called 
colostrum-corpuscles.  Similar  fatty  degenerations  probably  occur  in  the  cells 
of  the  sebaceous  glands.  Certain  processes  in  the  hepatic  cells  are  on  the 
boundary  line  between  a  normal  and  a  pathological  production  of  fat.  Here, 
too,  the  fatty  change  consists  in  the  appearance  of  small  fat-granules  within 
the  liver-cells.  But  the  hepatic  cells  may  contain  a  normal  quantity  of  fat- 
granules,  and  may  also  undergo  extensive  pathological  fatty  degeneration.  In 
a  state  of  disease,  all  cells  and  all  living  derivatives  of  cells  may  undergo 
fatty  degeneration. 

The  essence  of  fatty  degeneration  consists  in  a  production  of  fat  by  the  cell. 
The  cell  can  transform  constituents  of  its  own  body  into  fat,  or,  differently 
expressed,  constituents  of  the  cell  can  be  converted  by  chemical  decomposition 
into  fat  (and  into  some  other  products  of  decomposition).  The  cell  can  at  the 
same  time  continue  to  live.  It  is  true,  the  fat-granules  act  as  foreign  bodies 
on  the  cell-body;  hence  the  presence  of  fat-granules  probably  involves  a  dis- 
turbance of  function  ;  but  it  does  not  exclude  a  continuation  of  this  function. 
If  considerable  portions  of  the  cell  are  transformed  into  fat,  the  disturbance 
naturally  increases.  Under  no  circumstances,  however,  can  we  consider  the 
fatty  cell,  or  of  course  the  fatty  muscle,  as  incapable  of  recovery.  The  fat- 
granules  can  be  absorbed  ;  they  can  also  be  expelled,  and  the  remaining  living 
matter  can  continue  to  perform  its  function  and  can  even  recover  entirely  by 
means  of  tissue-metamorphosis.  I  say  it  can,  if  the  conditions  are  favorable ; 
especially  if  the  cause  of  the  progress  of  the  fatty  degeneration  ceases  to  act. 
If  the  fatty  degeneration  makes  headway,  it  may  finally  interfere  so  much 
with  the  performance  of  function  as  to  cause  death ;  if,  for  example,  it  im- 
plicates the  substance  of  the  heart. 

1  It  is  a  matter  of  dispute  -whether  adipose  tissue  is  a  tissue  of  its  own  kind,  or  whether  it  is 
altered  connective  tissue. 


62  PATHOLOGY   OF   INFLAMMATION. 

Amyloid  Degeneration  undoubtedly  depends,  as  was  first  asserted  by  Vir- 
chow,1  on  a  metamorphosis  of  the  tissue  to  that  peculiar  substance  which  we 
call  amyloid.  Amyloid  indicates  that  it  is  related  to  amylum.  This  suspicion 
is  based  on  the  reaction  with  iodine,  discovered  by  Meckel  and  Virchow.2 
The  reliability  of  the  iodine  reaction  has  been  cmestioned,but  Bottcher  reasserts 
that  it  is  the  best  of  all.  He  employs  a  mixture  of  25  centigrammes  of  iodine, 
50  of  iodide  of  potassium,  with  100  cubic  centimetres  of  water,  and  adds  dilute3 
sulphuric  acid.  More  recently,  methyl  compounds  have  been  recommended. 
This  reagent  stains  the  amyloid  substances  red,  but  the  healthy  tissue  blue. 
But  this  test  has  also  been  reported  as  unreliable  by  Kyber.4 

With  regard  to  the  chemical  composition  of  the  amyloid  substance,  E. 
Ludwig  has  favored  me  with  the  following  data : — 

According  to  the  analyses  of  Friedreich  and  Kekule,  as  well  as  those  of  Kiihne  and 
RudnerT',  it  shows  a  composition  very  nearly  approaching  that  of  the  alhuminous  bodies. 
It  is  soluble  in  concentrated  hydrochloric  acid,  from  which  water  precipitates  a  body 
having  the  properties  of  syntonin  hydrochlorate.  Amyloid  substance  is  soluble  in 
potassa  or  soda  lye,  and  the  solution  has  the  properties  of  an  alkaline  albuminate.  E. 
Modzejewski  obtained  tyrosine  and  leucine  as  products  of  decomposition  of  the  amyloid 
substance,  by  acting  on  it  with  boiling  dilute  sulphuric  acid  ;  he  supposes  that  the  amy- 
loid  substance  gives  the  same  products  of  decomposition  as  albuminous  bodies.  From 
the  putrefaction  of  amyloid  substance  Th.  Weyl  obtained  the  same  products  that  fibrin 
yields  in  putrefaction.  It  is  apparent  from  all  of  these  observations  that  the  amyloid 
substance  is  very  closely  allied  in  its  chemical  properties  to  albuminous  bodies. 

These  data  are  still  too  meagre,  however,  to  permit  of  conclusions  being 
drawn  as  to  the  nature  of  the  process.  But  we  may  be  sure  of  one  thing. 
The  amyloid  degeneration  cannot  be  compared  to  the  inflammatory  meta- 
morphosis of  tissue.  The  amyloid  constituents  of  tissue  are  lifeless..  The 
cell,  the  capillary  wall,  or  the  basis-substance  which  has  become  entirely 
changed  into  amyloid  matter,  can  no  longer  take  active  part  in  the  functions 
of  the  organism.  The  same,  it  is  true,  also  holds  good  for  those  constituents 
of  the  tissue  which  have  undergone  fatty  degeneration.  But  it  is  important 
to  lay  stress  upon  the  difference  between  the  two.  Fat  can  be  more  easily 
dissolved  and  absorbed.  The  amyloid  substance,  however,  seems  to  burden 
the  tissue  permanently.  Hence  a  cure  {restitutio  ad  integrum)  of  amyloid 
organs  is  hardly  to  be  thought  of. 

Calcareous  Degeneration. — Just  as  the  tendency  to  produce  fat  resides  in 
certain  tissues,  so  other  tissues  again  have  the  property  of  depositing  lime 
salts.  Bone  and  cartilage  belong  to  this  class.  Inasmuch  as  cartilage  is 
converted  into  bone,5  it  must  deposit  lime  salts  in  its  basis-substance.  But 
cartilage  calcines  sometimes  (as  for  example  under  the  influence  of  slight 
inflammatory  stimuli)  without  being  converted  into  bone.  Of  pathological 
calcifications  of  other  tissues,  too  little  is  known  besides  the  mere  fact  that 
they  do  occur,  to  warrant  my  considering  them  here. 

Colloid  Degeneration. — Tn  conclusion,  T  present  some  remarks  with  regard 
to  colloid  degeneration,  for  which  I  am  likewise  indebted  to  E.  Ludwig. 

The  colloid-substance  in  its  chemical  properties  approaches  most  nearly  to  mucin, 
but  differs  therefrom  by  its  solubility  in  acetic  acid.     Eichwald   regards  the  colloid 

'  Charite"  Annalen,  1853.  2  Virchow's  Archiv,  Bd.  viii.,  1854. 

8  Said  to  be  Beve:n  per  cent. 

4  Virchow's  Archiv,  Bd.  lxxxi.,  1880.  Kyber  also  praises  the  reaction  with  iodine  and  sul- 
phuric acid. 

5  The  occurrence  "f  a  direct  transformation  <>f  cartilage  into  bone  is  now  probably  quite  certain  : 
but  this  is  not  the  only  method  of  its  formation. 


DEGENERATION    OF    THE    TISSUES.  63 

material  as  a  modified  mucin,  representing  a  transition  from  mucin  to  muco-peptone. 
Wurtz  examined  the  gelatin  from  a  colloid  cancer  of  the  lung  ;  it  was  insoluble  in  water, 
and  by  evaporating  to  dryness  was  converted  into  a  white  laminated  mass,  which  gave, 
after  extraction  with  alcohol  and  ether,  a  white  powder  that  in  turn  again  swelled  into 
gelatin.  Potassa  and  soda  lye  dissolved  the  gelatin,  and  acetic  acid  precipitated  it 
from  solution.  An  elementary  analysis  of  the  dry  substance  gave  48.09  per  cent,  of 
carbon,  7.47  per  cent,  of  hydrogen,  7  per  cent,  of  nitrogen,  37.44  per  cent,  of  oxygen. 
This  composition  varies  considerably  from  that  of  all  known  albuminous  bodies  ;  it 
approaches  the  composition  of  chitin.  It  is  probable  that  the  colloid  material  can  be 
converted  into  mucus. 


INFLAMMATION. 


BY 

WILLIAM  H.  VAN  BUREN,  M.D.,  LL.D., 

PROFESSOR  OF  THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY  IN  TIIE  BELLEVUE  HOSPITAL  MEDICAL 

COLLEGE,   NEW  YORK. 


General  Considerations  regarding  Inflammation.    Definitions. 

The  pathology  of  inflammation,  as  interpreted  by  the  methods  of  the  his- 
tologist,  having  been  fully  set  forth  in  the  preceding  article,  it  remains  to 
describe  this  complex  but  important  condition,  so  constantly  under  the  eye 
of  the  surgeon,  from  the  standpoint  of  clinical  observation. 

The  definitions  of  inflammation  furnished  by  the  latest  teachings  of  science, 
although  their  correctness  is  not  disputed,  do  not  convey  the  full  significance 
of  the  term  as  employed  in  the  ordinary  language  of  the  surgery  of  the  day. 
In  this,  supreme  importance  is  ascribed  to  the  objective  symptoms  of  pain, 
heat,  redness,  and  swelling,  as  originally  enumerated  by  the  Roman  surgeon 
Celsus  in  his  definition  of  inflammation  which  has  become  classical ;  and  the 
idea  of  fiery  excitement  which  suggested  the  early  use  of  the  Greek  adjective 
'•  phlogistic,"  and  its  Latin  synonym  "  inflammatory,"  are  always  present  in 
the  mind.  Thus,  if  a  wound  is  described  as  "  inflamed,"  the  idea  intended 
to  be  conveyed  is  that  some  of  the  cardinal  symptoms  just  mentioned  are 
present,  whereas  simple  primary  union  may  take  place,  or  even  granulations 
and  suppuration  may  go  on,  without  either  pain,  heat,  redness,  or  swelling  in 
a  noticeable  degree;  and  yet  primary  adhesion,  granulation,  and  suppuration 
are  certainly  legitimate  features  of  the  inflammatory  process  as  we  now  com- 
prehend it.  The  definitions  heretofore  proposed  are  more  or  less  imperfect,  in 
consequence  of  the  obscurity  which  belongs  to  the  subject.  Those  entitled 
to  most  respect  simply  describe  inflammation  as  the  aggregate  of  the  pheno- 
mena which  are  set  in  action  by  any  lesion  of  the  organism  affecting  its 
tissues  locally,  provided,  of  course,  that  the  tissues  involved  have  not  been 
killed  outright.  It  is  obvious  that  the  phenomena  which  attend  the  kindly 
healing  of  a  simple  incised  wound  are  not  fully  recognized,  in  the  popular 
sense  of  the  word,  as  belonging  to  the  same  "series  of  changes"  which  culmi- 
nate in  the  more  violent  manifestations  of  inflammation  and  result  in  sup- 
puration, ulceration,  and  possibly  gangrene.  These  latter  are  regarded  as 
belonging  to  true  inflammation. 

To  reconcile  this  absence  of  conformity,  which  is  readily  explained  by  a 
glance  at  the  recent  advances  in  the  science  of  surgery,  Sir  James  Paget  has 
employed  the  phrase  "  process  of  repair"  to  designate  the  milder  phenomena 
of  inflammation  as  they  occur  in  healthy,  healing  wounds ;  and  more  re- 
cently Samuels  has  described  the  reparative  process  of  Paget  as  the  "  con- 
structive" phase  of  inflammation,  reserving  for  suppuration,  ulceration,  and 
gangrene  the  term  "destructive."  These  expressions,  which  indicate  truly 
the  results  of  the  process,  recognize  fully  an  identity  of  nature. 

vol.  i.— 5  (  65  ) 


66  INFLAMMATION. 

The  science  of  human  pathology,  which  took  its  origin  in  the  study,  after 
death,  of  the  anatomical  changes  of  the  diseased  organs  and  tissues  of  the 
body — morbid  anatomy,  as  it  is  usually  called — was  inaugurated  mainly  by 
the  French  school,  early  in  the  present  century.  Its  first  great  advances 
established  the  identity  of  what  was  called  inflammation,  as  manifested  on 
the  surface  of  the  body  and  in  wounds,  with  similar  conditions  affecting  its 
internal  organs,  an  identity  which  had  never  been  demonstrated.  Under  the 
influence  of  the  plausible  theories  of  Brown  and  Broussais,  inflammation,  thus 
advanced  to  a  more  extended  domain,  came  to  be  considered  as  the  most 
important  of  all  the  pathological  forces ;  an  uniform  termination  was  affixed 
to  the  names  of  inflammatory  diseases — itis — significant  of  the  afflux  of  blood 
to  the  inflamed  part — "  itio  in  -partes;''  and  the  treatment  of  the  diseases  thus 
distinguished,  which  formed,  according  to  their  assumption,  a  large  majority 
of  human  maladies,  was  of  necessity,  following  these  premises,  intrinsically 
antiphlogistic.  The  period  is  within  the  memory  of  the  writer  when  it  was 
the  dominant  doctrine  in  the  schools  that  inflammation,  in  some  form,  con- 
stituted the  essential  factor  in  most  diseases. 

The  application  of  the  microscope  to  the  study  of  morbid  anatomy  subse- 
quently demonstrated,  by  degrees,  the  existence  of  a  variety  of  degenerations 
and  other  morbid  changes  constantly  taking  place  in  the  tissues  and  organs 
of  the  body,  which  were  evidently  unconnected  in  any  way  with  inflamma- 
tion. Through  the  advance  in  more  accurate  knowledge,  inflammation  has 
therefore  ceased  to  be  regarded  as  such  an  omnipresent  disease ;  it  has  come 
to  be  considered,  in  fact,  as  in  no  respect  an  essential  disease,  but  rather  a 
condition  liable  to  be  provoked  in  the  organism  by  certain  harmful  influences, 
called  for  convenience  the  causes  of  inflammation ;  a  condition  located 
mainly  in  the  apparatus  of  nutrition,  affecting  a  limited  area,  and  consisting 
in  a  temporary  perversion  of  the  mechanism  of  nutrition  from  its  natural  and 
regular  order,  which  is  characterized  by  a  series  of  phenomena  already  de- 
scribed by  the  histologist,  and  to  be  hereafter  considered  from  a  clinical  point 
of  view  under  the  title  of  symptoms  of  inflammation. 

It  should  not  be,  therefore,  a  matter  of  surprise  that  the  terms  employed 
in  treating  of  inflammation,  including  indeed  the  word  itself,  have  been 
gradually  changing  their  signification  in  accordance  with  the  growth  of  more 
precise  knowledge ;  and,  lest  the  mind  should  be  influenced  by  the  more  vague 
and  pretentious  meaning  heretofore  attached  to  these  terms,  the  fact  of  this 
change  in  signification  should  be  held  in  constant  remembrance.  The  term 
inflammation  will  be  employed  in  the  ensuing  pages  as  including  the  series 
of  textural  changes — microscopic,  as  well  as  macroscopic — which  take  place 
in  living  tissues  after  they  have  been  subjected  to  injury.  For  the  sake  of 
convenience,  the  term  "constructive"  will  be  applied  to  the  phenomena  of 
afflux,  exudation,  cell  germination,  the  formation  of  new  capillary  vessels,  and 
the  development  of  cicatricial  tissue— in  other  words,  to  the  inflammatory 
phenomena  which  constitute  the  simple  uncomplicated  "process  of  repair;'' 
whilst  the  additional  presence  of  suppuration,  ulceration,  or  gangrene,  and 
all  other  harmful  complications  of  the  process,  will  be  included  under  the 
term  "•destructive." 

In  this  connection  it  maybe  observed  that  inflammation  has  heretofore 
been  treated  of  by  systematic  writers  as  a  disease^  with  certain  characteristic 
features,  and  tending  to  certain  "terminations."  The  convenience  of  this 
mode  of  handling  the  subject  is  obvious;  but  its  scientific  correctness  is  open 
to  question.  In  popular,  and  also  in  professional  language,  it  is  common  to 
speak  of  "an  attack  of  inflammation"  as  of  an  attack  of  tetanus;  and  the 
remedial  measures  employed  in  its  treatment  have  been  habitually  designated 
as  "antiphlogistic."     .Now,  inflammation,  although  presenting  in  some  of  its 


GENERAL    CONSIDERATIONS    REGARDING    INFLAMMATION — DEFINITIONS.       67 

phases  well-marked  features  which  in  a  popular  sense  might  justify  the  use 
of  this  term,  does  not  possess  the  essential  qualities  of  a  disease  in  the  more 
precise  language  of  science ;  and  it  cannot  be  spoken  of  as  a  disease  ontologi- 
cally.  In  very  many,  indeed  in  most  of  its  phases,  it  is  a  benign,  healthful 
process  to  which,  even  in  its  popular  sense,  the  appellation  of  disease  would 
be  regarded  as  inapplicable. 

It  is  better,  therefore,  with  our  incomplete  knowledge,  to  assume  that  in- 
flammation is  a  process  more  or  less  abnormal,  or  a  condition — not  even  in  a 
majority  of  instances  a  morbid  condition — presenting  as  its  characteristic 
features  a  series  of  textural  changes  typically  uniform  in  character,  although 
varying  widely  in  aspect,  and  leading  to  different  results  according  to  the 
nature  and  degree  of  persistence  of  the  causes  which  have  given  rise  to  it. 
This  designation  is  as  proper,  and  as  intrinsically  correct,  as  when  the  word 
condition  is  applied  to  a  local  numbness,  to  intoxication,  to  pregnancy,  or  to 
the  moribund  state. 

When  the  causes  which  have  given  rise  to  inflammation  cease  to  act,  the 
features  which  characterize  the  condition  disappear;  it  has  no  inherent  power 
of  continuance  beyond  that  which  has  been  impressed  by  injury  of  some  sort 
upon  the  local  nutritive  machinery.  The  textural  changes  which  belong  to 
the  condition,  as  far  as  they  are  objective,  constitute  its  symptoms ;  as  far  as 
these  changes  are  subjective,  they  constitute  its  pathology.  The  means  which 
have  been  found  to  modify  these  symptoms  favorably,  or  which,  through  a 
knowledge  of  their  course,  may  be  rationally  expected  to  lead  to  such  a  result, 
constitute  its  remedies,  and  will  be  considered  under  the  head  of  treatment. 

These  considerations  occur  naturally  to  the  surgeon  familiar  with  the 
clinical  aspects  of  inflammation  in  any  attempt  to  bring  them  into  causal 
relation  with  the  histological  phenomena  by  which  they  are  explained.  Until 
this  relation  is  established  there  is  no  solid  basis  from  which  to  reason  in 
studying  its  symptoms  in  detail,  and  its  treatment  is  of  necessity  entirely  em- 
pirical. Histology  teaches  us  that  the  essential  features  of  the  inflammatory 
process  are,  an  increased  afflux  of  blood  to  the  affected  part,  with  an  exagge- 
rated tendency  to  cell  proliferation  and  tissue  formation.  A  knowledgeTof 
the  mechanism  of  this  process  affords  the  only  rational  explanation  of  the 
various  manifestations  which  it  presents  to  the  unaided  eye ;  and,  when  com- 
bined with  clinical  observation  and  experience,  this  knowledge  gives  us  all 
the  power  we  can  safely  exercise  in  favoring  its  constructive  tendencies,  and  in 
averting  or  controlling  its  proclivity  to  destructive  results. 

It  may  be  proper  to  remark,  in  this  connection,  that  the  destructive  phases 
of  the  inflammatory  process  do  not  apparently  arise  from  any  noxious  quality 
inherent  in  the  process  itself,  but,  rather,  from  the  intrinsically  defective 
power  of  the  human  structure  to  resist  and  repair  injuries.  Naturalists  have 
taught  us  that  this  power  of  repairing  injuries  exists  in  a  much  greater  de- 
gree in  the  lower  animals  than  in  our  complex  organisms.  The  destructive 
phases  of  inflammation  are  also  explained  in  some  degree  by  the  degradation 
in  vital  quality  of  our  tissues  which  results  from  unhealthful  habits  of  life, 
and  surroundings  defective  as  to  hygiene;  by  the  more  aggravated  character 
of  injuries  rendered  possible  by  human  ingenuity — as  exemplified  in  gunshot 
rounds;  and  by  ignorance  of  the  real  nature  and  scope  of  our  reparative 
powers,  and  the  means  by  which  they  may  be  aided  and  supplemented.  The 
truth  of  the  last  averment  is  rendered  probable  by  the  increased  power  of 
repair,  the  greater  rapidity  with  which  the  reparative  process  is  accomplished, 
and  the  remarkable  infrequency  of  the  destructive  symptoms  of  inflammation 
manifested  in  wounds  which  have  been  subjected  to  judicious  drainage  and 
treated  early  and  skilfully  in  accordance  with  the  antiseptic  method. 


68  INFLAMMATION. 

The  present  account  of  inflammation  will  include  its  causes,  symptoms,  varie- 
ties, consequences,  and  complications — viewed  especially  in  reference  to  its  man- 
agement in  the  practice  of  surgery. 


Causes  of  Inflammation. 

The  causes  of  inflammation  determine,  in  a  great  degree,  the  attitude  to  he 
assumed  by  the  surgeon  in  its  judicious  treatment,  for  they  exercise  a  direct 
influence  upon  its  constructive,  or  destructive,  tendency ;  there  is,  therefore, 
no  department  of  the  subject  more  worthy  of  careful  study. 

Irritation  and  Injury. — In  accordance  with  doctrines  which  were  long 
dominant  in  medicine,  "  irritation,"  acting  upon  any  of  the  tissues  or  organs 
of  the  body,  was  held  to  be  the  immediate  exciting  cause  of  inflammation ; 
and  the  development  of  irritation  in  any  locality  was  supposed  to  invite  the 
flow  of  blood  towards  it — the  first  step  in  the  inflammatory  process.  Hence 
the  apothegm  "tTfo"  irritatio ,  ibi  affluxus."  The  term  "irritant,"  habitually 
employed  as  synonymous  with  "an  inflammation-producing  agent,"  has  in 
more  recent  times  given  place  to  "  injury."  The  latter  has  become  a  technical 
term  in  surgical  pathology,  signifying  that  ivhich  is  capable  of  impairing  the 
vital  quality  of  the  tissues.  It  is  used  in  this  sense  in  a  form  of  definition  of 
inflammation,  which  has  become  classical:  "the  series  of  changes  that  follow 
injury,  provided  the  injury  has  not  been  so  severe  as  to  cause  the  death  of  the 
part"  (Burdon  Sanderson).  An  "injury,"  then,  may  be  regarded  as  compe- 
tent to  inaugurate  the  "  series  of  changes"  that  constitute  inflammation. 

It  is  worthy  of  notice,  as  illustrating  the  purposive  tendency  of  inflamma- 
tion, that,  at  its  inception,  if  not  in  its  later  phases,  it  is  mainly,  if  not  entirely, 
constructive.  It  can  hardly  be  doubted  that  the  "series  of  changes"  following 
a  lesion  which  has  not  absolutely  destined  textural  life,  have  for  their  object 
the  repair  of  the  lesion;  this  is  apparently  demonstrated  by  the  result,  which, 
if  the  inflammation  does  not  transcend  certain  limits,  is  almost  invariably 
curative. 

There  is  a  limited  analogy,  as  to  their  immediate  consequences,  between 
the  influence  of  a  surgical  "injury,"  and  the  fertilizing  of  an  ovum;  both 
stand  in  the  relation  of  cause  and  effect  to  a  sequence  of  changes  which  lead 
directly  to  cell  proliferation  and  tissue  formation.  Rindfleisch  tells  us,  in 
fact,  that  he  prefers  to  study  the  process  of  embryonic  cell  development,  under 
the  microscope,  in  inflamed  tissues. 

Classification  of  Causes. — As  employed  in  connection  with  the  causes  of 
inflammation,  the  term  injury  includes  the  endless  variety  of  wounds,  hurts, 
and  lesions,  of  every  possible  nature,  to  which  our  organisms  are  exposed. 
Tin ■  manifold  sources  of  injury  arc  advantageously  arranged  in  three  classes : — 

(1)  Those  arising  from  physical  force  or  mechanical  violence — as  cuts,  stabs, 
fractures  of  bone,  dislocations  of  joints,  and  laceration,  bruising,  or  crushing 
of  limbs,  or  <>!'  internal  organs. 

(2)  Those  arising  from  irritating  or  destructive  chemical  action — as  from 
heal  in  any  form,  such  as  burns  and  scalds  from  strong  acids,  or  caustic  alka- 
lies, from  tin'  action  of  cold,  etc 

(3)  Those  arising  from  poisonous  infection,  as  from  the  venom  of  insects 
and  serpents,  from  a  virus,  as  of  glanders,  or  syphilis,  from  the  miasm  due  to 
the  infinite  diffusion  of  poisonous  microscopic  organisms, or  their  germs. 

Many  of  the  individual  injuries  thus  classified  have  been  recognized  in  all 
times  as  determining  causes  of  inflammation.     Others,  again,  and  mainly 


CAUSES    OF    INFLAMMATION.  69 

those  of  the  third  class — the  injurious  micro-organisms — have  only  recently 
been  brought  under  the  cognizance  of  the  pathologist  as  the  immediate  de- 
termining causes  of  the  more  destructive  phases  of  the  inflammatory  process. 
There  is  promise  of  great  benefit  to  humanity  and  of  equal  credit  to  surgery 
in  the  fact  that  its  pathology  has  been  enriched,  though  the  philosophic  acu- 
men and  admirably  patient  research  of  one  of  its  own  devoted  students,  by  the 
demonstration  of  this  still  novel  cause  of  inflammation;  and  the  gain  to  hu- 
manity and  to  surgery  has  been  incalculably  magnified  by  the  correlative 
discoverv  of  effective  remedial  measures,  actual  and  preventive,  for  the  various 
forms  of  destructive  inflammation  thus  traced  to  their  source. 

John  K.  Mitchell,  of  Philadelphia,  before  1849,  expressed  a  strong  belief 
in  the  cryptogamic  origin  of  the  poisons  generally  known  as  miasmata,  and 
ably  defended  the  theory  that  most  malignant  fevers  were  due  to  this  source.1 
Pasteur,  in  1865,  discovered  the  cryptogamic  micro-organism  which  caused 
the  epidemic  silkworm  disease  in  France,  and  demonstrated  its  direct  agency 
in  perpetuating  the  disease.  The  next  year,  Lister,  assuming  by  induction 
that  a  similar  source  of  poisonous  infection  might  be  capable  of  preventing 
the  normal  process  of  repair  of  wounds,  inaugurated  a  course  of  experimental 
research  which  has,  in  the  opinion  of  many,  amply  demonstrated  the  propo- 
sition. As  this  interesting  subject  will  be  discussed  in  a  separate  article,  it  is 
not  necessary  to  pursue  it  here  beyond  the  recognition  of  poisonous  germs  as 
a  pregnant  cause  of  inflammation  in  its  worst  forms. 

Following  the  general  classification  which  has  been  laid  down,  we  shall 
study,  with  concurrent  details,  some  of  the  typical  causes  which  clinical 
observation  has  shown  to  be  capable  of  exciting  inflammation,  seeking,  in 
each,  for  indications  as  to  the  means  by  which,  ultimately,  this  condition 
may  be  prevented  or  controlled.  In  the  first  place,  however,  it  will  be 
necessary  to  notice  certain  general  considerations  which  necessarily  form 
part  of  a  study  of  the  causes  of  inflammation  ;  and,  also,  to  define  the  mean- 
ing of  certain  terms  commonly  used  in  treating  of  this  subject. 

Most  systematic  writers  speak  of  inflammation  as  traumatic,  or  idiopathic, 
in  accordance  with  its  origin  from  obvious  injury,  or  the  reverse — and,  when 
there  is  no  discoverable  cause  for  its  occurrence,  it  is  assumed  to  arise  spon- 
taneously. 

The  terms  idiopathic  and  spontaneous,  as  applied  to  inflammation,  are  con- 
venient, but  they  are  of  doubtful  accuracy.  It  is  not  certain  that  either  of 
them  is  in  any  case  correct,  in  a  scientific  sense.  It  is  exceedingly  improb- 
able that  the  series  of  textural  changes  of  which  the  inflammatory  process  is 
believed  to  consist  can  be  set  in  action  without  a  provoking  cause.  These 
terms  have  come  to  be  habitually  used  under  the  assumption  that  inflamma- 
tion is  a  disease.  In  fact,  they  are  only  admissible  as  signifying  that  the 
source  of  origin  of  the  inflammatory  condition  is  not,  at  the  moment,  demon- 
strable. 

-Again,  the  terms  internal  and  external  inflammation,  as  applied  to  the  con- 
dition when  it  occurs  in  the  interior  of  the  body,  or  upon  its  surface,  are 
employed,  somewhat  vaguely,  as  synonymous  with  medical  and  surgical,  in 
accordance  with  French  nomenclature,  which  designates  medical  pathology 
as  internal,  and  surgical  pathology  as  external.  This  use  of  words  perpetuates 
the  idea  that  there  is  a  radical  difference  between  medical  and  surgical 
pathology ;  an  idea  which  is  no  longer  tenable.  There  has  been  a  time  when 
the  surgeon  was  content  to  leave  the  examination  of  internal  organs  to  the 
physician,  before  as  well  as  after  death,  but,  since  the  functions  of  the  surgeon 
and  physician  have  become  so  inseparably  blended  as  they  are  at  the  present 

1  On  the  Cryptogamous  Origin  of  Malarious  and  Epidemic  Fevers.    Philadelphia,  1849. 


70  INFLAMMATION. 

day,  this  fashion  has  passed  away.  The  expert  (as  he  is  now  properly  styled) 
in  either  of  these  branches  of  medicine  finds  his  knowledge  advantageously 
supplemented  by  deferring  to  the  histological  pathologist,  who,  in  the  exer- 
cise of  his  peculiar  methods,  is  also  an  expert  in  the  more  accurate  interpre- 
tation of  the  appearances  of  morbid  anatomy. 

To  illustrate  the  correlation  of  medicine,  surgery,  and  histology,  it  may  be 
mentioned  that  Curling  first  called  attention  to  the  relation  between  burns  of 
the  surface  of  the  body  and  the  ulceration  of  the  duodenum  which  so  often 
accompanies  them  ;  and  Erichsen  emphasizes  the  fact  that  death  ascribed  to 
the  shock  of  injury  and  to  exhaustion,  is  often  explained,  in  the  dead-house, 
by  the  discovery  of  laceration  of  the  liver.  Jaccoud  and  Ferrier  have  obtained 
most  of  their  illustrations  of  intra-cranial  pathology  from  well-observed 
cases  of  surgical  injuries  of  the  head.  The  histologist  has  taught  us  that 
senile  gangrene,  formerly  attributed  to  arteritis,  is  in  fact  caused  by  calcific 
degeneration  of  the  arterial  coats,  and  by  thrombosis  and  embolism ;  and 
that  arteritis,  formerly  supposed  to  be  a  common  occurrence,  is  in  reality  a 
rare  condition. 

Predisposing  and  Exciting  Causes. — Systematic  writers  usually  lay  much 
stress  upon  the  distinction  between  what  are  called  the  predisposing  causes  of 
inflammation  and  its  immediately  exciting  or  determining  causes.  An  example 
will  illustrate  the  meaning  of  these  terms :  A  growing  boy,  overheated  by 
exercise,  goes  into  the  water  to  bathe,  or  throws  himself  on  the  ground  in  the 
shade  to  rest.  During  the  following  night  he  is  awakened  by  a  severe  pain 
in  the  thigh,  which  is  continuous  as  well  as  severe,  and  finally  results  in  a 
necrosis  from  limited  osteo-myelitis.  In  such  a  case,  which  is  of  common 
occurrence,  the  activity  of  the  nutritive  process  in  the  rapidly  growing  bone 
of  the  adolescent,  and  exhaustion  incident  to  the  fatigue  incurred,  are  the 
predisposing  causes ;  and  the  rapid  abstraction  of  heat  from  the  body  by  the 
cold  water,  or  the  cool  earth — the  chilling,  in  fact — is  the  exciting  cause  of 
the  inflammation.  These  two  classes  of  causes  are  also  designated  as  remote 
and  proximate.  Most  of  the  sources  of  injury  classified  above  are  examples 
of  proximate  or  exciting  causes. 

Predisposing  Causes  or  Inflammation. — The  most  obvious  and  important 
of  the  remoter  causes  which  predispose  a  part  or  an  organ  to  take  on  the  con- 
dition  of  inflammation,  is  defect  in,  quality  of  the  blood.  When  we  reflect  that 
all  the  organs  and  tissues  of  the  body  are,  as  it  were,  enveloped  in  an  atmos- 
phere of  liquor  sanguinis,  and  that  they  are  continually  absorbing  from  it  the 
materials  required  to  maintain  them  in  a  normal  state  of  health,  it  is  easy  to 
comprehend  how  a  variation  in  the  quality  of  this  fluid  necessarily  disturbs 
the  nutrition  of  the  tissues,  and,  as  a  consequence,  may  diminish  their  vital 
capacity  of  resisting  injury,  and  also  of  repairing  it  when  incurred.  In  the 
language  of  the  older  surgeons,  "a  vitiated  state  of  the  blood  is  a  very  com- 
mon cause  of  the  ill  behavior  of  wounds  in  regard  to  their  kindly  healing." 
Now,  habitual  excess  of  food  and  drink,  and  also  habitual  lack  of  proper 
food  and  deprivation  of  an  adequate  supply  of  pure  fresh  air,  which  prevents 
elimination  of  the  products  of  textural  waste,  equally  tend  to  impair  the 
quality  of  the  blood,  and  consequently  of  the  tissues  supplied  by  it;  so  that 
slight  injuries,  which  in  a-  state  of  health  would  take  on  prompt  repair, 
under  these  unfavorable  circumstances  linger  in  healing,  and  run  into  suppu- 
ration,  or  into  partial  or  molecular  gangrene;  at  other  times  they  become 
indolent,  refuse  to  cicatrize,  or  remain  indefinitely  in  the  condition  known  as 
chronic  inflammation.  As  common  examples,  taken  from  clinical  observation, 
the  following  are  cases  in  point: — 


CAUSES   OF    INFLAMMATION.  71 

A  man  of  middle  age,  of  sedentary  occupation,  living  too  well,  in  apparently  full 
health  hut  perhaps  slightly  defective  in  complexion  and  fhibhy  in  muscle,  in  consequence 
of  the  slight  violence  caused  by  straining  at  stool,  is  taken  with  painful  swelling  in  the 
ischio-rectal  fossa,  which  results  in  an  extensive  abscess,  followed  by  tardy  and  imper- 
fect repair,  and  leading  to  chronic  fistula  in  ano,  or  even  to  danger  of  death. 

In  another  case  a  half-starved  child  is  seized  with  a  hard  swelling  in  the  thickness  of 
the  cheek,  which  in  a  few  days  turns  black  at  its  centre,  and  results  in  perforation, 
constituting  the  form  of  disease  known  as  noma,  or  gangrcenopsis. 

The  presence  of  a  poison  in  the  blood,  whether  this  fluid  is  otherwise  impov- 
erished or  not,  may  predispose  to  inflammation.  This  is  seen  in  the  peculiar 
behavior  of  lesions,  not  arising  directly  from  the  disease,  in  persons  affected 
by  syphilis:  instead  of  healing  in  a  healthy  manner,  they  are  liable  to  take  on 
the  aspect  of  syphilitic  ulcers,  and  to  require  anti-syphilitic  treatment  for  their 
cure.  The  condition  of  the  blood  in  diabetes  mellitus  begets  a  well-marked  , 
predisposition  to  hypersemia  of  the  intestinal  mucous  membrane,  and  to  erup- 
tions of  the  skin.  An  eczema  of  the  genitals  may  have  proved  obstinate  under 
the  use  of  ordinary  remedies,  but  as  soon  as  the  presence  of  sugar  is  discovered 
in  the  urine  and  the  patient  is  restricted  to  a  diet  of  animal  food,  the  local 
inflammation  tends  to  get  well.  Blood  of  defective  quality,  especially  when 
certain  poisons  are  present  in  it,  tends  to  stagnate  in  limited  areas,  probably 
through  its  lack  of  full  power  to  stimulate  the  heart  and  bloodvessels.  The 
local  hyperemia  which  results  from  this  tendency  often  constitutes  the  first 
stage  in  the  development  of  inflammation.  Hence  the  frequency  of  serous 
effusions  in  uraemia.  Da  Costa  and  Longstreth1  speak  of  an  "outburst  of  in- 
flammation of  the  serous  membranes" — e.g.  intense  pericarditis,  with  pleural 
and  peritoneal  effusion — the  result  of  altered  blood  in  Bright's  disease,  the 
patient  having  suffered,  also,  from  ursemic  coma. 

The  occurrence  of  eczema  in  the  gouty  is  directly  provoked  by  the  acrid 
qualities  of  the  perspiration.  It  is  remotely  favored  by  the  condition  of  the 
blood ;  and  "  the  gouty  irritability"  of  the  membranes,  which  is,  in  other  words, 
a  state  of  nervous  hyperesthesia,  is  caused  by  the  same  condition  of  blood. 
In  proof  of  this  we  may  point  to  the  marked  relief  to  these  symptoms  which 
usually  follows  "a  crisis"  of  gout,  in  which  the  blood  has  relieved  itself  of  its 
impurities.  Here  is  a  typical  example  of  what  is  usually  spoken  of  as  the 
influence  of  a  diathesis  in  favoring  the  occurrence  of  inflammation ;  and  it 
illustrates  what  is  true  of  all  the  so-called  diatheses,  namely,  that  their  influ- 
ence, if  it  can  be  properly  so  styled,  is  recognized  mainly  in  the  accidents 
which  result  from  the  peculiar  constitutional  quality.  Another  example  of 
the  predisposing  influence  of  a  diathesis  is  to  be  found  in  the  meningitis  of 
early  life,  which  is  often  excited  by  tubercular  deposit  in  the  vicinity  of  the 
bloodvessels  of  the  pia  mater;  the  so-called  tubercular  diathesis  acting  as  a 
remote  cause  of  the  inflammation. 

The  influence  of  a  defective  or  deranged  nervous  supply  to  parts  is  in  some 
instances  easily  recognized  as  a  remote  cause  of  local  inflammatory  action. 
Certain  inflammations  of  the  skin,  especially  the  herpetic  eruptions,  furnish 
illustrative  examples  of  this  influence.  Thus  Von  Bserensprung  has  shown 
that  herpes  zoster  is  always  coincident  with  alteration  in  the  anatomical  ele- 
ments of  the  intervertebral  ganglion  situated  upon  the  posterior  or  sensitive/ 
root  of  the  spinal  nerves  supplying  the  affected  parts.  This  form  of  skin  dis- 
ease occurs  also  in  regions  supplied  by  the  trifacial  nerve,  and  is  accompanied 
by  local  anesthesia  of  the  inflamed  integument,  and  a  tendency  to  local  death. 
The  development  of  a  vesicle  of  herpes  on  the  cornea  has  been  followed  by  the 

1  American  Journal  of  Medical  Sciences,  July,  18S0. 


72  INFLAMMATION. 

formation  of  a  slough.  In  a  case  in  which  the  ganglion  of  Gasser  was  subse- 
quently found  bathed  in  pus,  the  whole  eye  shrank  and  collapsed.  An  erup- 
tion of  herpes  about  the  lips  after  a  paroxysm  of  malarial  fever,  or  as  conse- 
quence of  functional  gastric  disturbance,  is  a  very  common  occurrence.  The 
formation  of  abscess  in  the  vicinity  of  a  focus  of  inflammation,  as  of  a  diseased 
joint,  when  not  the  result  of  a  secondary  or  infectious  process,  has  been  attri- 
buted to  reflex  nervous  irritation.  Hyperseniic  congestion,  with  local  evidences 
of  altered  nutrition,  has  been  observed  in  parts  of  which  the  nerves  have 
been  wounded  or  divided.  The  rapidity  with  which  bed-sores  form  on  the 
sacrum  after  exhausting  fevers  and  surgical  lesions  of  the  spinal  cord  causing 
paraplegia,  is  well  known;  and  the  occurrence  of  cystitis  in  such  cases  is  a 
constant  result.  Bed-sores  begin  by  intense  hyperemia  of  the  integument, 
followed  by  vesicular  eruption,  or  pustulation,  so  that  the  lesion  is  at  first 
distinctly  inflammatory ;  but  it  is  usually  complicated  by  local  death  of  tissue. 

The  period  of  life  has  less  influence  than  has  usually  been  ascribed  to  it  as 
a  predisposing  cause  of  inflammation.  Examples  are  frequently  cited  in  favor 
of  this  cause,  which  are  not,  in  reality,  inflammatory  affections.  The  effects 
of  malnutrition  in  infants,  or  of  the  senile  atrophy  or  degeneration  of  tissue 
incident  to  age,  have  been  attributed  to  inflammation.  In  childhood,  the  pro- 
cess of  nutrition  is  in  its  period  of  greatest  activity,  and  the  condition  of 
acute  hyperemia — the  first  step  towards  the  inflammatory  condition — occurs 
promptly  from  any  exciting  cause.  Any  interruption  of  nutrition  is  followed 
by  exaggerated  results  in  derangement  of  healthy  condition.  Fever  occurs 
readily,  and  from  slight  causes  of  provocation.  It  is  not  rare  to  see  a  weak, 
puny  infant  with  a  tendency  to  pus  formation  from  the  most  trifling  causes ; 
this  is  usually  traceable  to  a  defect  in  the  quality  of  the  blood,  the  result  of 
inadequate  nourishment,  or  to  the  eft'eet  of  poisonous  influences  upon  the 
tender  organism,  by  which  it  is  more  likely  to  be  affected  than  in  after  life. 
But  when  positive  inflammation  is  provoked  in  early  life,  if  its  processes  are 
rapid  in  their  evolution,  they  are  more  likely  to  be  limited  to  the  constructive 
stage  ;  and  there  is  in  the  infantile  organism  a  fund  of  vital  energy  available 
to  resist  and  to  repair  injury  which  is  very  remarkable.  Evidence  of  this  is 
to  be  seen  in  the  results  of  very  early  operations  for  hare-lip,  and  in  opera- 
tions for  imperforate  anus ;  and  in  the  striking  cures  effected  in  infantile 
syphilis  by  the  judicious  use  of  mercury. 

On  the  other  hand,  in  the  aged,  affections  peculiar  to  this  period  of  life,  often 
referred  to  as  inflammatory,  are  really  of  a  different  nature:  neither  prostatic 
disease  nor  senile  gangrene  is  due  to  inflammation.  The  former,  like  the 
uterine  tumors  of  the  other  sex,  is,  for  the  most  part,  due  to  fibroid  over- 
growth, and  the  latter  is  a  result  of  degeneration  of  the  arterial  coats.  The 
catarrhal  affections  of  age,  such  as  cystitis  and  conjunctivitis,  are  truly  inflam- 
matory, and  tend  to  pus  production.  They  arise  from  weakness  in  worn-out 
tissues  by  which  the  power  of  resistance  to  exciting  causes  of  inflammation 
is  impaired.  It  is  to  be  remarked  that  the  power  of  repair,  although  some- 
what slower  in  its  manifestations,  rarely  fails  through  age  alone.  This  is 
noticeable  in  the  constancy  with  which  a  good  immediate  result  is  obtained 
after  tlic  removal  of  epitheliomatous  cancers  so  common  at  this  period  of  life. 

In  middle  life,  the  greater  degree  of  exposure  to  traumatism,  to  the  influence 
of  poisons,  and  to  the  consequences  of  excess,  explains  the  greater  frequency 
of  inflammatory  affections  at  this  period.  Here,  also,  are  encountered  the 
contingencies  attending  "pregnancy  and  lactation,  which  so  often  tend  to  inflam- 
matory phenomena,  whether  by  traumatism,  the  poisons  to  which  the  puer- 
peral stale  exposes  the  patient,  or  the  peculiar  and  rapid  changes  to  which  the 
blood  is  liable  in  these  conditions.     It  would  be  wrong  to  omit  the  curious 


CAUSES    OF    INFLAMMATION.  73 

perturbations  of  the  nerve  force  which  also  attend  them.  There  is  a  remark- 
able tendency  to  pus  formation  developed  in  exceptional  instances,  'post  parturn, 
which  affects  the  joints  by  preference,  and  of  which  there  is  no  satisfactory 
explanation. 

Habit  of  bod}/,  etc. — It  was  formerly  a  common  belief  that  stout  and  full- 
blooded  persons  were  especially  liable  to  inflammation ;  that  they  were  in  a 
"  state  of  plethora'' — a  condition  of  morbid  fulness  of  the  bloodvessels,  indi- 
cating necessity  for  depletion.  But,  unless  habitually  over-fed,  there  is  no 
foundation  for  this  opinion.  Moderate  polysarcia  is  a  constitutional  pecu- 
liarity of  many  persons  who  enjoy  good  health.  The  habitually  ill-fed,  and 
those  who  from  any  cause  are  below  their  normal  weight,  are  more  likely  to 
do  badly  after  a  serious  injury  or  a  surgical  operation,  through  the  superven- 
tion of  some  of  the  unhealthy  complications  of  constructive  inflammation. 

Parts  which  have  been  already  the  seat  of  inflammation  are  more  likely 
to  fall  into  that  condition  subsequently,  from  slight  provocation,  than  tissues 
whose  vessels  have  never  been  subjected  to  previous  over-distension.  In  com- 
mon phrase,  "their  vitality  has  been  weakened."  This  is  also  true  of  parts 
which  have  been  exposed  to  prolonged  or  extreme  cold,  or  which  have  been 
frozen.  The  habitual  congestion,  the  itching,  and  the  proneness  to  vesication 
and  ulceration  so  commonly  observed  in  chilblains,  illustrate  this  predisposing 
cause  of  inflammation.  It  is  probable  that  in  addition  to  impairment  in 
quality  of  the  vascular  tissues  in  parts  thus  "weakened,"  their  nerves  have 
also  suffered  in  a  similar  way. 

Every  organ  whilst  in  active  use  receives  more  blood,  and  is,  for  the  time, 
hypersemic.  Habitual  functional  hypercemia,  especially  when  associated  with 
fatigue  from  prolonged  or  excessive  use  of  an  organ,  is  a  not  uncommon  pre- 
disposing cause  of  inflammation.  Thus,  reading  all  night  is  liable  to  be  fol- 
lowed by  suppurative  inflammation  of  one  or  more  of  the  Meibomian  follicles 
— the  ordinary  hordeolum,  or  sty ;  and  if  this  excess  be  frequently  repeated, 
the  tissues  of  the  eyeball  itself  are  pretty  certain  to  suffer  from  inflammation 
in  some  form,  if  exposed  to  an  exciting  cause. 

A  young  gentleman  fatigued  and  heated  by  active  ball  play  seated  himself  to  rest  by 
an  open  window  where  he  was  exposed  to  a  draught  of  cool  air.  The  next  morning  the 
muscles  of*  the  shoulder  and  arm  were  the  seat  of  excessive  pain  on  the  slightest  motion, 
in  consequence  of  the  development  of  a  condition  of  "  subacute  inflammation"  of  the 
muscular  tissues. 

In  regard  to  the  influence  of  climate,  and  of  meteorological  phenomena,  in 
predisposing  the  organism  to  inflammation,  certain  facts  have  been  observed. 
In  tropical  regions,  inflammations  of  the  eyes  of  a  serious  character  are  very 
common  and  prevalent.  So,  also,  is  dysentery ;  and  abscess  of  the  liver  is  a 
frequent  occurrence.  The  latter  affection  is  very  rare  in  cold,  or  even  in  tem- 
perate climates.  In  the  latitude  of  New  York,  the  summer  heats  predispose 
to  inflammations  of  the  intestinal  canal,  especially  in  children,  tending  to 
culminate  in  ileo-colitis.  In  cold  weather,  the  air  passages  are  more  prone  to 
inflammatory  affections,  of  which  the  most  common  is  bronchitis.  March 
winds,  as  was  pointed  out  over  two  thousand  years  ago  by  Hippocrates,  were, 
in  the  Morea,  as  they  are  with  us,  the  frequent  causes  of  acute  phlegmasia — 
of  tonsillitis,  bronchitis,  and  conjunctivitis;  evidently  because  they  favor  sud- 
den chilling,  and  give  rise  to  irritation  by  producing  clouds  of  dust. 

In  our  climate,  the  seasons  of  the  year  which  have  been  found  most  favor- 
able for  surgical  operations,  as  regards  freedom  from  inflammatory  complica- 
tions, are  the  midsummer  and  autumnal  months.     This  is  explained  by  the 


74  INFLAMMATION. 

freer  access  of  fresh  air.  In  the  comparatively  severe  cold  of  the  winter,  and 
the  changeable  weather  of  spring,  it  is  more  difficult  to  secure  healthy  con- 
ditions as  to  ventilation.  Erysipelas  occurs  more  frequently  in  the  late  win- 
ter and  early  spring  months. 

Exciting  Causes  of  Inflammation. — Strictly  speaking,  there  is  but  a  soli- 
tary cause  for  inflammation,  and  that  is  irritation  of  the  living  tissues  by 
something  which  is  called  an  irritant ;  and  this  act  constitutes,  technically, 
an  injarij.  But  there  is  an  endless  variety  of  irritants  which  may  be  sepa- 
rately recognized  and  classified  for  study  of  their  nature  and  mode  of  action, 
with  the  ultimate  purpose  of  modifying  their  influence  and  controlling  their 
injurious  effects.  This  constitutes  etiology,  the,  practical  value  of  which  lies 
entirely  in  its  bearing  upon  treatment.  We  have  enumerated  certain  of  the 
remote  influences  which  tend  to  invite  and  favor  the  action  of  irritants  in 
causing  inflammation  ;  and  we  have  next  to  examine  more  closely  the  nature 
and  qualities  of  the  more  immediately  exciting  causes  of  the  inflammatory 
movement,  so  that  we  may  be  able  to  intelligently  aid  and  favor  it,  as  far  as 
it  is  reparative  or  constructive,  or  to  avert  or  control  any  of  the  destructive 
phases  which  it  is  liable  to  assume. 

The  proximate  or  determining  causes  of  inflammation,  more  commonly 
spoken  of  as  exciting  causes,  may  act  upon  the  body  from  without,  as  when 
a  bullet  strikes  it ;  or  they  may  take  their  origin  within  the  body,  as  in 
epididymitis  from  tubercular  deposit,  or  eczema  from  diabetes.  This  sub- 
division of  the  causes  of  inflammation,  which  has  been  already  mentioned,  is 
followed  by  the  French  school.  The  external  causes  are  more  obvious  and 
easily  recognized  ;  the  internal  more  obscure,  and  these  cases  are  likely  to  be 
regarded  as  "  spontaneous"  or  "idiopathic."  It  may  be  inferred  from  what 
has  been  already  stated  concerning  the  inflammatory  predisposition,  that  the 
latter  is  more  commonly  present  in  connection  with  internal  causes,  for  in 
them  the  pre-existence  of  some  morbid  condition  of  the  organism  is  almost 
necessarily  assumed.  External  causes  of  inflammation  are  for  the  most  part 
either  traumatic  or  (to  adopt  a  parity  in  nomenclature)  toxic  in  their  nature, 
the  locality  in  which  the  inflammation  develops  itself  being  determined  more 
or  less  entirely  by  chance.  Internal  causes,  on  the  other  hand,  are  not  only 
aided  or  invited  by  some  predisposition  on  the  part  of  the  organism,  but  the 
part  or  organ  in  which  the  inflammation  locates  itself  is  in  most  instances 
also  determined  by  it. 

Coll  and  Sudden  Chilling  as  Causes  of  Inflammation. — There  is  a  frequent 
cause  of  inflammation  which  cannot  be  strictly  included  under  either  of  these 
Lends — cold  or  chilling — as  applied  to  the  whole  body,  or  to  a  part.  The 
ordinary  hyperaeniic  and  catarrhal  symptoms  which  so  commonly  follow 
chilling  of  the  body,  especially  of  the  feet,  are  familiar  to  all.  They  are 
caused  by  sudden  changes  in  the  constitution  of  the  blood  from  the  temporary 
arrest  of  function  of  the  skin  as  an  emunctory,  whereby  certain  effete  and 
presumably  noxious  materials  which  should  be  eliminated  are  retained  and 
net  iis  blood-poisons.  In  this  manner  ;i  species  of  temporary  intoxication  is 
produced.  The  resulting  inflammation  is  not  usually  of  a  serious  character, 
and  shows  a  certain  preference  lor  the  air-passages,  although  it  may  affect 
any  part  of  the  body  especially  a  part  that  has  been  previously  weakened. 
A  genera]  chilling  varies  greatly  in  the  degree  of  gravity  of  its  effects;  it 
may  involve  any  internal  organ  of  the  body,  and  to  such  an  extent  as  to 
prove  mortal. 

A  gentleman  of  28,  in  full  health,  stripped  himself  entirety  on  returning  home  from 
business,  on  an  exceptionally  hot  day,  and  threw  himself  on  a  lounge  before  an  open 


CAUSES    OF    INFLAMMATION.  75 

window  to  cool  off  before  dressing  for  dinner.  He  fell  asleep,  heedless  of  a  thunder- 
storm accompanied  by  a  decided  fall  in  the  temperature,  and  awoke  thoroughly  chilled. 
On  the  same  night  he  was  seized  with  a  rigor  which  proved  to  be  the  initial  symptom 
of  an  acute  general  peritonitis,  which  terminated  fatally  within  the  week. 

Severe  chilling  of  a  part  is  also  a  frequent  cause  of  inflammation.  \Vliat 
is  known  in  England  as  "  railway  paralysis"  is  the  result  of  inflammation  of 
the  facial  nerve,  or  its  neurilemma,  from  sitting  in  the  draught  of  an  open 
window  when  the  cars  are  in  rapid  motion. 

A  gentleman  had  a  severe  inflammation  of  the  epididymis  and  testis  which  led  to 
complete  atrophy  of  the  organ.  It  followed  a  chilling  of  t lie  testicle  from  sitting  for 
an  hour  upon  a  cold  stone  doorstep,  in  thin  clothing,  after  being  heated  in  walking. 
The  pendulous  organ  rested  upon  the  cold  seat  and  had  become  sensibly  chilled,  as  he 
noticed  at  the  time.  The  next  morning  it  was  painful  and  swollen.  The  inflammation 
subsided  in  a  week,  but  continuous  shrinkage  in  volume  of  the  organ  followed.  There 
was  no  urethral  lesion. 

Inflammatio  a  frigore,  as  the  ancients  called  it,  has  always  been  regarded, 
popularly  as  well  as  professionally,  as  a  very  common  occurrence — cold  being 
universally  received  as  a  sufficient  and  satisfactory  cause  of  the  inflammation. 
It  is  not  improbable  that  mortal  injury,  or  actual  necrosis,  of  some  of  the 
anatomical  elements  of  a  chilled  organ  may  set  in  action  the  series  of  changes 
which,  according  to  our  view  of  its  pathology,  constitute  inflammation ;  the 
blighted  elements  may  degenerate,  or  liquefy,  and  undergo  absorption ;  or 
the  inflammation  which  their  presence  has  excited  may  culminate  in  abscess, 
and  thus  effect  their  expulsion  from  the  organism. 

Reverting  to  the  classification  of  causes  which  have  been  recognized  as 
competent  to  excite  the  inflammatory  process,  we  shall  proceed  to  examine 
in  detail  the  most  typical  of  them. 

Incised  Wounds. — There  is  no  form  of  mechanical  violence  that  excites 
inflammation,  in  which  the  process  is  developed  more  Uniformly  in  its  benign 
or  constructive  form  than  in  division  of  the  tissues  with  a  sharp  knife  so  as 
to  produce  an  "  incised  wound,"  such,  in  fact,  as  that  made  by  the  surgeon 
in  cutting  operations.  And  yet  a  scalpel  with  the  keenest  edge  cuts  on  the 
principle  of  the  saw,  and  invariably  leaves  in  the  wound  myriads  of  micro- 
scopic particles  of  lacerated  tissue.  These  are  carried  away  in  part  by  the 
flow  of  blood  and  the  subsequent  liquid  exudation,  and  the  rest  undergo 
liquefaction  and  absorption  by  the  lymphatics.  They  do  not  apparently 
interfere  with  the  kindly  succession  of  changes  which,  when  the  cut  surfaces 
are  quietly  retained  in  proper  apposition,  bring  about  prompt  union  "  by  the 
first  intention."  These  changes  are  exudation,  cell-proliferation,  the  genera- 
tion of  new  capillaries  which  inosculate  across  the  breach  of  continuity,  and 
the  organization  of  a  film  of  cicatricial  tissue,  often  hardly  visible,  by  which 
Nature's  "first  intention"  is  completed.  This  happy  phrase  by  which  Hunter 
described  the  phenomenon  of  "  primary  union,"  was  applied  to  a  result  accom- 
plished by  what  he  called  "  adhesive  inflammation."  The  discovery  of  the 
microscopic  mechanism  of  this  process  has  not  impaired  in  any  degree  the 
aptness  of  the  phraseology  of  the  great  observer.  It  is  for  us  to  notice  that, 
in  its  most  perfect  results,  our  senses  detect,  in  the  process  of  primary  union, 
neither  pain,  heat,  redness,  nor  swelling  ;  simply  the  healing  of  a  textural 
breach  by  a  nutritive  act,  effected  without  excitement,  and  by  an  apparently 
competent  mechanism.  Whilst  admiring  the  perfection  of  this  typical 
expression  of  the  reparative  act,  our  part  is  to  detect,  if  possible,  the  causes 
which  lead  to  such  frequent  deviations  from  its  simple  effectiveness,  and,  if 
possible,  to  prevent  obstacles  to  its  uniform  accomplishment.     The  sources  of 


76  INFLAMMATION. 

injury  next  to  be  considered — stabs  and  punctured  wounds — often  present 
features  and  complications  by  which  a  result  so  desirable  as  that  just  described 
is  prevented. 

Punctured  Wounds. — Puncture  by  a  smooth  polished  instrument  resembles 
an  incision,  and,  if  the  track  of  the  wound  be  kept  at  rest,  and  subjected  to  gen- 
tle pressure  in  order  to  keep  the  divided  surfaces  in  contact,  it  generally 
heals  kindly.  Wounds  made  by  surgical  needles  for  suture,  exploration,  or 
aspiration,  are  examples ;  even  trocar  wounds  heal  promptly.  Thus,  when 
the  tissues  are  simply  divided  and  thrust  aside,  there  is  no  cause  for  compli- 
cations ;  but  from  a  puncture  made  by  a  rough  instrument,  as  where  a  rusty 
nail  perforates  the  sole,  larger  particles  of  tissue  are  liable  to  be  killed,  and 
foreign  matter  is  apt  to  be  left  in  the  wound. 

4 

Hie  presence  in  a  wound,  of  foreign  material  is  a  very  common  source  of 
interference  with  the  healthy  process  of  repair.  Hence  the  formal  rule 
enjoining  its  careful  removal  before  dressings  are  applied.  In  the  first  place, 
it  prevents  accurate  contact  of  divided  parts,  a  condition  absolutely  necessary 
for  prompt  healing.  In  the  second  place,  the  presence  of  a  foreign  body  in 
contact  with  the  living  tissues,  as  a  rule,  acts  as  an  irritant,  and  ushers  in  a 
series  of  phenomena  which  have  for  their  purpose  its  expulsion  from  the 
organism.  These  are,  afflux  of  blood  to  its  vicinity,  the  germination  of  em- 
bryonic cells,  their  accumulation  in  the  form  of  pus,  and  ulceration  in  the 
direction  of  the  nearest  free  surface,  by  which  a  free  vent  is  gained,  and  the 
foreign  substance  is  thus  thrown  oft".  These  phenomena  are  attended  by  pain, 
heat,  redness,  and  swelling,  and  they  constitute  a  phase  of  inflammation 
which  attains  a  degree  of  intensity  that  involves  destruction  of  tissue.  Tins 
forms  at  once  a  contrast  with  the  simple  process  of  repair.  There  are  excep- 
tions to  the  rule  that  foreign  bodies  act  as  irritants,  and  provoke  suppurative 
inflammation.  Some  of  the  metals,  such  as  lead,  silver,  and  iron,  are  in  a  cer- 
tain degree  tolerated  by  the  tissues,  causing  only  a  grade  of  inflammation 
which  ends  in  tissue  formation,  and  they  become  finally  enveloped  by  a  sac 
of  connective  substance  called  technically  a  cyst ;  they  are  said  to  be  encysted. 
But  these  exceptions  serve  only  to  prove  a  rule.  This  is  exemplified  by  what 
Furbringer,  of  Jena,  sa}rs  of  hypodermic  injections  of  metallic  mercury :  that 
"  they  are  well  borne,  but  within  twenty-four  hours  inflammatory  symptoms 
set  in,  and  frequently  result  in  abscess." 

Our  own  tissues,  when  from  any  cause  deprived  of  life,  become  foreign 
bodies  and  constitute  the  most  common  examples  of  irritants,  even  when  the 
dead  masses  are  quite  minute.  The  ordinary  boil  is  due  to  this  cause,  which 
may  be  demonstrated  by  examining  its  core  microscopically.  The  core  of  a 
boil  consists  of  a  little  slough  of  connective  substance,  mainly  of  the  yellow 
elastic  fibres,  containing  in  its  meshes  some  leucocytes  or  pus  cells.  This 
small  mass  has  become  necrosed,  and  its  white  fibrous  element  has  liquefied 
and  mingled  wi.h  the  pus;  but  its  yellow  fibres,  one  of  the  most  indestructi- 
ble of  all  the  simple  tissues,  remain  unchanged  and  constitute  the  foreign 
body  the  presence  of  which  has  excited  the  suppurative  inflammation.  Ne- 
crosis of  connective  substance  in  minute  masses  is  not  a  rare  occurrence.  It 
i-  due  to  some  detect  in  nutritive  quality  of  the  blood,  or  of  the  nervous  sup- 
ply transmitted  to  the  tissues.  Its  cause  is  obviously  central,  and  not  local; 
for  boils  often  occur  in  indefinite  succession  in  different  localities  ;  and  their 
tendency  to  recurrence  is  distinctly  controlled  by  the  internal  use  of  certain 
drugs  which  modify  favorably  the  blood  and  the  nerve  force,  such  as  arsenic, 
sulphide  of  calcium,  and  the  nypophosphites.  Certain  blood  jwisons  give  rise 
to  disseminated  tissue  necroses.     In  smallpox,  each  pustule  is  evolved  for  the 


CAUSES    OF   INFLAMMATION.  77 

expulsion  of  a  disk  of  dead  true  skin.  Hence  the  depressed  cicatrices  or 
'•  pits"  which  these  minute  abscesses  leave  behind  them.  The  death  of  a 
portion  of  osseous  tissue,  from  scrofulous  malnutrition,  or  from  a  traumatism, 
as  when  a  scale  of  bone,  giving  attachment  to  a  muscle,  is  torn  off  in  some 
violent  effort,  or,  in  fact,  necrosis  from  any  cause,  is  a  common  source  of  ori- 
gin of  deep  abscess. 

Foreign  substances  liable  to  provoke  inflammation  by  lodging  in  the  body 
include  bullets,  cloth,  splinters  of  bone,  of  wood,  and  all  the  materials  liable 
to  be  associated  with  gunshot  projectiles  and  explosive  compounds  of  every 
variety ;  and,  with  the  exceptions  mentioned,  the  inflammation  provoked  by 
them  is  attended  by  suppuration.  Gunshot-wounds  are,  in  a  certain  sense, 
rough  punctures. 

In  considering  lesions  of  bone  by  mechanical  force,  in  their  relation  to  in- 
flammation, we  encounter  at  once  a  remarkable  clinical  feature — not,  indeed, 
peculiar  to  this  tissue,  but  typically  illustrated  by  its  behavior  under  injury. 
In  a  large  proportion  of  lesions  of  bone,  simple  fractures,  for  example,  the  in- 
flammatory condition  is  limited  entirely  to  its  constructive  phenomena,  very 
rarely  transcending  the  boundaries  of  the  process  of  repair.  On  the  other  hand, 
in  a  comparatively  small  proportion  of  them — the  compound  fractures — the 
inflammation  often  assumes  its  most  destructive  aspects;  and  these  constitute 
a  grave  and  critical  class  of  surgical  cases.  In  the  former,  uncomplicated 
and  satisfactory  repair  is  the  usual  result;  in  the  latter,  there  is  frequently 
loss  of  limb  and  loss  of  life.  Formerly  it  was  held  that  the  additional  vio- 
lence inflicted  on  the  soft  parts  accounted  for  the  difference  in  the  amount 
and  character  of  the  inflammation  occurring  in  compound  fractures ;  this 
complication  being  regarded  as  a  sufficient  explanation  of  their  increased 
gravity.  But  we  have  gradually  learned  from  clinical  experience,  largely 
from  the  success  of  Stromeyer's  operations  upon  tendons  and  fascire — in  which 
these  parts  were  cut  across  by  a  small  knife  inserted  through  a  minute  wound 
which  was  promptly  closed  and  sealed — that  the  subcutaneous  character  of 
the  lesion  affords  the  true  explanation  of  the  greater  safety  in  simple  frac- 
ture, and  that  exposure  of  the  injured  parts  to  the  air  is  the  source  of  danger 
in  compound  fracture.  Surgical  operations  for  the  relief  of  deformities,  as 
previously  practised,  had  proved  so  dangerous  that  they  were  rarely  resorted 
to,  until  the  German  surgeon  demonstrated  that  the  method  just  described 
was  uniformly  safe.  It  has  become  a  received  doctrine  in  surgery  that,  not 
only  in  fracture,  but  in  any  lesion  whatever,  when  the  external  air  is  excluded, 
the  phenomena  of  inflammation  that  follow  are  restricted  to  those  of  the  be- 
nign or  constructive  order. 

The  explanation  of  this  interesting  fact,  that  subcutaneous  lesions  are  uni- 
formly repaired  by  constructive  inflammation,  the  discovery  of  which  has 
added  vastly  to  the  safety  and  utility  of  operative  surgery,  has  been  sought 
for  in  various  directions.  Addison  ascribed  it  to  the  uniformity  and  to  the 
elevation  of  the  temperature  at  which  the  injured  parts  were  preserved  during 
the  subcutaneous  process  of  healing.  He  recognized  the  close  resemblance 
between  the  vital  phenomena  of  reparative  inflammation  and  those  of  embry- 
onic development,  as  studied  in  the  egg  of  the  chick  during  incubation,  and 
correctly  inferred  that  the  conditions  which  nature  always  secured  for  the 
latter  (in  warm-blooded  animals)  would  be  most  favorable  to  the  process  of 
repair;  and  that  liability  to  frequent  chilling  would  be  as  harmful  to  the  pro- 
gress of  healing  as  it  was  in  the  process  of  incubation. 

Afore  recently  Lister  is  seeking  to  demonstrate  that  the  apparently  noxious 
influence  ascribed  to  the  air  is  not  due  to  any  intrinsic  qualities  of  the  air, 
but  to  the  presence  in  it,  under  almost  all  conceivable  circumstances,  of  mi- 
croscopic germs  of  micro-organisms.    He  asserts,  in  accordance  with  Pasteur's 


78  INFLAMMATION. 

demonstration  of  their  habits,  as  ascertained  by  their  cultivation  in  different 
media,  that  these  organisms  iind  in  the  raw  and  exposed  surfaces  of  our  tis- 
sues avenues  of  entrance,  and  that  they  at  once  encounter  materials  which 
constitute  a  suitable  pabulum  for  their  germination  and  development.  The 
j>resence,  in  the  soft  vital  materials  of  a  recent  wound,  of  myriads  of  micro- 
organisms multiplying,  at  their  expense,  with  the  inconceivable  rapidity  of 
cryptogamic  fungi,  accomplishes  the  destruction  of  their  vital  and  chemical 
properties,  and  entirely  unfits  them  for  use  in  the  process  of  repair.  Repara- 
tive inflammation  fails,  therefore,  for  want  of  material,  and  is  replaced  by 
the  condition  which  constitutes  destructive  inflammation.  Pasteur's  dis- 
covery of  the  fermentative  nature  of  putrefaction,  and  his  proofs  of  the  pro- 
duction of  this  process  by  the  struggle  for  life  of  minute  organisms  like  the 
torula  of  the  yeast  plant,  lends  verisimilitude  to  the  doctrines  advocated 
by  Lister.  At  the  present  time  they  afford  the  most  probable  explanation  of 
the  habitually  more  favorable  results,  as  to  healing,  of  wounds  excluded  from 
contact  with  the  air,  and  of  the  greater  mortality  of  compound  fractures  as 
heretofore  treated.  The  evidence  upon  which  this  conclusion  is  based  is  de- 
rived from  clinical  observation  of  the  more  favorable  results  obtained  by 
treating  compound  fractures  in  accordance  with  the  antiseptic  method,  which 
aims  to  destroy  or  exclude  all  microscopic  aerial  germs. 

The  germ  theory  of  disease,  and  its  bearing  upon  inflammation,  is  a  subject 
which  presents  a  degree  of  importance  at  the  present  time,  to  which  it  is  dif- 
ficult to  place  a  limit.  No  study  of  the  exciting  causes  of  inflammation  can 
approach  completeness  without  a  full  consideration  of  its  claims  to  credence, 
and  a  due  estimate  of  their  value.  It  will  be  necessarily  discussed  hereafter 
in  connection  with  the  toxic  exciting  causes  of  inflammation. 

Mechanical  violence  that  results  in  wrenching,  straining,  dislocation  of  joints, 
affecting  principally  the  white  fibrous  tissues  composing  the  ligaments,  and 
the  tendons  with  their  sheaths,  produces,  for  the  most  part,  lesions  not  exposed 
to  contact  of  the  air.  The  inflammation  that  follows. is,  therefore,  rarely 
otherwise  than  simply  reparative.  Compound  dislocations,  however,  present 
most  of  the  unfavorable  features  of  compound  fractures. 

Contusion  of  living  tissues  involves  not  only  a  possible  breach  of  continuity, 
but  also,  to  a  variable  extent,  entire  or  partial  destruction  of  textural  life.  In 
every  contused  wound  of  any  severity,  there  are  liable  to  be  sloughs,  or  parts 
entirely  killed,  which  must  be  separated,  or  thrown  off,  by  a  vital  process 
before  final  healing  can  take  place.  There  are,  also,  parts  often  described  as 
half-killed,  that  is,  so  tar  injured  as  to  render  their  survival  a  matter  of  doubt 
— certainly,  of  delay.  This  complex  condition  includes  several  exciting  causes 
of  inflammation  besides  the  general  stimulus  to  repair  that  follows  every  in- 
jury. To  this  stimulus  the  tissues  which  have  been  simply  divided,  but  not 
otherwise  seriously  damaged,  are  alone  in  a  condition  to  respond.  Hence  the 
rule,  in  dressing  contused  wounds — to  bring  the  surfaces  together  as  for  pri- 
mary union,  but  with  very  moderate  retentive  force,  in  order  to  test  the 
capacity  of  the  doubtfully  injured  portions  to  undergo  the  changes  which  ac- 
company constructive  inflammation,  and  to  secure  any  advantage  that  may 
be  attainable. 

( )!'  the  parts  in  a  contused  wound  which  have  been  damaged,  but  not  en- 
tirely killed,  a  portion  may  recover  and  participate  in  the  healing;  whilst  the 
rest,  sooner  or  later,  die.  The  delay  required  to  determine  the  fate  of  the 
doubtful  part-  renders  suppuration,  under  ordinary  dressings,  unavoidable. 
The  process  of  separation  of  dead  from  living  parts,  under  ordinary  cir- 
cumstances, has  heretofore  rendered  granulation  and  suppuration  inevitable. 


CAUSES   OF    INFLAMMATION.  79 

The  presence  of  dead  tissue  in  a  wound,  before  a  granulating  surface  lias  be- 
come organized,  involves  a  certain  danger  of  septic  poisoning.     The  necessary 

occurrence  of  these  several  sources  of  irritation  in  a  contused  wound,  as  conse- 
quences of  its  nature  and  mode  of  production,  explains  the  greater  liability 
to  inflammatory  complications  of  this  form  of  surgical  injury.  In  lesions  of 
the  internal  viscera  from  mechanical  violence,  when  they  are  of  moderate 
extent  and  do  not  implicate  large  bloodvessels,  it  is  probable  that  healing 
often  takes  place  without  any  recognition,  or  even  suspicion,  of  the  existence 
of  such  a  lesion — the  uniform  high  temperature  of  the  injured  part  favoring 
prompt  repair,  as  in  a  subcutaneous  wound.  This  is  rendered  probable  by 
the  discovery  of  recent  cicatrices  in  the  lungs,  liver,  and  kidneys  in  patients 
who  have  died  from  the  later  consequences  of  coexisting  external  injuries. 

It  is  evident,  from  this  brief  survey  of  the  exciting  causes  of  inflammation 
arising  from  mechanical  violence,  that,  as  far  as  we  can  learn  from  clinical 
observation,  these  causes  act  primarily,  and,  in  fact,  mainly,  by  stimulating 
the  process  of  repair.  Deviations  from  the  simple  constructive  process  which 
may  manifest  themselves  subsequently,  in  the  progress  of  a  case,  are  explained : 
first,  by  the  conditions  peculiar  to  the  injury,  e.g.,  the  necessity  for  getting 
rid  of  matters  foreign  to  the  economy  in  order  to  accomplish  healing,  and  by 
other  causes  of  delay  in  the  process;  secondly,  by  the  accidental  interference 
of  noxious  agents  which,  by  acting  directly  upon  a  wound,  impair  the  quality 
of  the  materials  furnished  by  the  organism  for  healing  it. 

The  j)resence  of  a  clot  of  blood  of  any  size  in  a  wound  has  always  been  re- 
garded as  a  possible  cause  of  at  least  partial  failure  of  union,  and  of  pus  forma- 
tion-. Thus,  bleeding  in  a  stump  after  the  ordinary  mode  of  dressing,  in 
consequence  of  failure  to  secure  a  vessel  which  has  bled  after  reaction,  or  from 
inadvertent  bruising,  or  injudicious  pressure,  has  often  been  the  cause  of  pro- 
longed heat  and  pain,  and  of  fever  protracted  beyond  the  usual  limit,  and 
finally  of  suppuration,  abscess,  and  sinus.  To  prevent  repetition  it  may  be 
stated  here,  that  this  very  frequent  cause  of  inflammation  which,  combined 
with  the  presence  in  the  wound  of  ordinary  ligatures  of  silk,  has  been,  hereto- 
fore, one  of  the  most  common  causes  of  ill  behavior  in  wounds,  has  been  found 
by  recent  clinical  experience  to  be  preventible  by  the  use  of  antiseptic  dressings 
and  ligatures  of  prepared  catgut.  When  these  precautions  have  been  care- 
fully employed,  clots  even  of  considerable  size  have  been  observed  to  shrink 
and  lose  their  color,  and  to  become  organized  by  the  appearance  in  their  sub- 
stance of  embryonic  cells  and  newly-formed  capillaries,  and  to  assist  directly 
in  forming  a  bond  of  union.  The  prevention  of  putrefaction  by  the  antiseptic 
method,  a  result  which  can  always  be  commanded,  apparently  favors  the  more 
perfect  accomplishment  of  the  constructive  process.  In  recent  experiments 
on  animals,  masses  of  living,  and  even  of  dead  (but  not  putrid)  tissue,  have 
been  successfully  included  in  the  peritoneal  cavity,  and  have  become  organized.1 

1  A  paper  was  presented  at  the  Berlin  Medical  Congress  of  April,  1SS0,  by  Dr.  A.  Rnsenherger, 
of  Wurzburg  (Archiv  fur  klinische  Chirurgie),  on  this  subject.  Having  observed  that  foreign 
bodies  and  ligatured  portions  of  tissue,  e.  </.,  the  returned  pedicle  after  ovariotomy,  etc.,  caused 
no  trouble,  as  a  rule,  in  operations  conducted  antiseptically,  Dr.  R.  introduced  pieces  of  living 
muscle,  and  even  whole  kidneys,  with  antiseptic  precautions,  into  the  serous  cavities  of  animals 
without  any,  or  with  only  the  very  slightest,  reaction.  After  a  time  the  pieces  of  living  tissue 
disappear  without  leaving  a  trace.  The  tissue  need  not  be  from  the  same  animal,  or  even  from 
the  same  species  of  animal.  The  process  seems  to  be,  at  first,  one  of  encapsulation.  From  the 
capsule  cells  wander  into  the  inclosed  tissue  and  break  it  up.  The  capsule  receives  a  capillary 
network  from  its  surroundings,  and  the  foreign  tissue  thus  nourished,  if  it  come  from  an  animal 
of  the  same  species,  may  continue  to  live  on.  In  certain  cases  of  partial  failure,  amongst  those 
in  whom  masses  of  dead  tissue  previously  soaked  for  many  days  in  alcohol  had  been  introduced, 
a  pus  cavity  was  found  in  the  centre  of  the  foreign  mass,  which  had  become  permeated  by  leuco- 
cytes and  by  new  capillary  loops.     (Medical  News  and  Abstract,  May,  18S1.) 


80  INFLAMMATION. 

It  is  a  circumstance  of  daily  observation  that  a  slighter  degree  of  mechanical 
disturbance  than  any  of  the  sources  of  injury  heretofore  described,  not  amount- 
ing to  violence,  but  more  or  less  persistent  in  character,  is  capable  of  begetting 
a  condition  of  local  hyperemia,  and,  if  continued,  of  exciting  positive  inflam- 
mation. This  is  exemplified  by  the  friction  of  the  skin  by  articles  of  clothing ; 
and  by  the  action  of  cold  winds  upon  the  surface.  The  normal  motions  of  a 
joint  are  competent  to  excite  inflammation  of  a  higher  grade  in  a  trifling 
lesion  in  process  of  healing,  seated,  perhaps,  on  its  dorsal  aspect,  as  for  example 
an  abrasion  of  a  knuckle — which  is  so  likely  to  fester.  In  other  words,  the 
simple  process  of  repair  whilst  in  kindly  progress,  is,  by  this  ioim  of  excita- 
tion, liable  to  be  irritated  to  the  point  of  suppuration. 

A  blacksmith  received  a  kick  from  a  horse  upon  the  knee.  After  a  few  days'  rest, 
as  the  contusion  had  ceased  to  be  painful,  he  resumed  his  work.  But  pain  about  the 
knee  soon  returned,  and  some  days  later  he  was  brought  to  the  New  York  Hospital 
with  much  fever  and  an  acute  fluctuating  swelling  around  the  joint,  simulating  inflam- 
mation of  the  joint  itself.  After  evacuation  of  the  abscess,  the  case  did  well.  The 
patient,  who  was  addicted  to  beer,  and  thus  predisposed  to  suppurative  inflammation, 
explained  in  regard  to  his  condition  that  he  had  been  doing  perfectly  well  after  the  acci- 
dent, but,  on  returning  to  his  work,  "  he  must  have  taken  cold,  and  then  inflammation 
set  in."  The  true  explanation  of  the  occurrence  of  destructive  symptoms  in  this  case 
was  the  irritation  inflicted  upon  parts  undergoing  the  process  of  repair  by  too  early  re- 
sumption of  the  use  of  the  joint.  By  this  exciting  cause  the  constructive  grade  of 
inflammation  was  disturbed  in  its  progress,  and  converted  into  suppurative  inflammation. 

Slight  but  persistent  mechanical  action  must  therefore  be  recognized  as  one  of 
the  exciting  causes  of  inflammation.  It  is  a  frequent  cause  of  interruption 
and  of  complication  of  the  healing  process,  and  its  power  of  doing  harm  is 
very  commonly  underestimated.  Its  bearing  upon  the  great  value  of  quies- 
cence as  a  remedial  agent  in  inflammation  will  be  hereafter  considered. 

T7?e  action  of  a  chemical  irritant  in  exciting  inflammation  is  illustrated  by 
the  phenomena  which  follow  the  application  of  a  drop  of  nitric  acid  to  the 
surface  of  the  skin.  Within  a  minute  or  two,  an  increased  redness  is  percep- 
tible immediately  surrounding  the  drop  of  acid.  This  area  of  redness  steadily 
extends,  growing  more  intense  in  color,  until  it  attains  a  diameter  of  two  or 
three  inches.  At  the  same  time  there  is  a  slight  increase  of  fulness  and  heat 
in  the  part.  Within  the  hour,  these  symptoms  may  have  disappeared.  The 
redness,  due  to  acute  hyperemia,  has  passed  away,  as  have  all  the  symptoms 
except  a  scarcely  perceptible  circle  bounding  the  margin  of  the  yellow-tinted 
eschar  produced  by  the  action  of  the  acid  upon  the  epidermis  and  the  true 
skin — which  latter  is  involved  to  a  depth  measured  by  the  strength  of  the 
acid.  After  a  day  or  two  even  this  narrow  circle  of  redness  vanishes,  and  at 
the  end  of  a  fortnight  the  yellow  eschar,  which  has  become  somewhat  darker 
in  color,  becomes  detached,  disclosing  a  smooth  cicatrix,  of  a  positively  red 
color,  invested  with  epidermis.  These  phenomena  represent,  typically,  the 
1  >ehavior  of  most  chemical  irritants  as  excitants  of  inflammation.  Their  action 
is  limited  to  that  of  a  simple  stimulus  to  repair;  and,  when  severe  enough  to 
produce  death  of  tissue,  the  sloughs  are  thrown  oft' without  suppuration,  pro- 
vided  that  the  air  has  been  excluded,  or  that  antiseptic  dressings  have  been 
employed.  Burns  by  phosphorus  would  seem  to  constitute  an  exception,  as 
the  acid  generated  by  the  combustion  of  the  phosphorus  acts  as  an  additional 
irritant  to  the  raw  surface. 

Heat  produces  results  similar  to  those  of  the  potential  cautery,  but  in  greater 
variety.     It  may  cause  a  simple  blush  of  transient  hyperemia,  or  vesication, 


CAUSES    OF    INFLAMMATION.  81 

or  death  of  tissue — superficial,  or  deep.  The  inflammation  following  simple 
burns,  or  scalds,  if  no  eschars  have  been  formed,  is  limited  to  simple  repair, 
especially  if  the  air  is  excluded  from  the  seat  of  injury.  When  there  is  death 
of  tissue,  the  separation  of  the  eschars,  as  a  rule,  involves  suppuration.  Re- 
pair by  the  second  intention,  that  is,  by  granulation  and  suppuration,  often 
fails,  in  extensive  burns,  through  lack  of  cicatricial  power,  and  from  other 
causes;  but,  if  we  except  pyaemia  during  suppuration,  inflammation,  as  such, 
rarely  leads  to  a  fatal  result  in  burns. 

There  is  an  opinion  prevalent  amongst  practical  surgeons  that  the  unhealthy 
forms  of  inflammation  are  less  likely  to  follow  in  wounds  to  which  the  actual 
cautery  has  been  applied,  or  where  incisions  have  been  made  by  the  incandes- 
cent knife.  It  is  also  a  common  belief  that  healthy  reparative  inflammation 
is  promoted  by  the  application  of  the  caustic  acids  and  alkalies.  This  is 
probably  founded,  at  least  in  a  measure,  upon  their  efficiency  in  destroying 
poisoned  surfaces,  e.  g.,  venereal  and  phagedenic  ulcers,  and  parts  attacked  by 
hospital  gangrene.  Of  the  escharotics  in  vogue  of  late,  the  chloride  of  zinc 
enjoys  much  reputation  through  its  reputed  antiseptic  quality;  and  there  is 
evidence  that  the  liberal  application  of  an  eight  per  cent,  solution,  which  is 
decidedly  escharotic,  to  a  recent  wound,  does  not  interfere  with  its  subsequent 
union  by  the  first  intention — certainly  under  antiseptic  dressing. 

The  mode  which  we  have  adopted  of  studying  inflammation,  by  scrutiniz- 
ing the  causes  which  have  been  proved  to  be  capable  of  producing  this  condi- 
tion in  our  tissues,  and  the  manner  in  which  these  causes  act,  has  led,  thus 
far,  to  the  recognition  of  two  well-marked  grades  of  the  inflammatory  pro- 
cess. One  of  these  is  the  simple  form  of  repair  which  constitutes  Hunter's 
union  by  the  first  intention;  the  other  is  the  process  of  healing  by  the  second 
intention,  or  by  suppuration  and  granulation.  It  has  also  been  recognized 
that  tissues  which  have  been  damaged  by  injury  sometimes  die  in  the  effort 
at  repair,  and  apparently  in  consequence  of  it.  The  exciting  causes  which 
next  present  themselves  for  examination,  namely,  the  sources  of  jwisonous  in- 
fection, are  more  various  in  their  nature,  and  also,  in  some  of  their  forms, 
more  obscure  in  their  mode  of  action  than  those  heretofore  under  considera- 
tion. Although  the  existence  and  the  noxious  influence  of  some  of  these 
sources  of  injury  has  long  been  suspected,  they  have,  until  recently,  escaped 
general  recognition.  The  effects  of  the  inflammation-producing  poisonous 
agents  upon  the  organism  cover  a  wider  range  than  those  exciting  causes 
which  act  only  mechanically,  or  chemically.  In  addition  to  their  action  upon 
the  tissues  generally,  some  of  these  poisons  exert  a  specially  noxious  influence 
directly  upon  the  nervous  centres.  Many  of  them  possess,  also,  the  peculiar 
power  of  perpetuating  their  poisonous  influence,  after  their  introduction  into 
the  organism,  by  a  process  allied  in  its  nature  to  that  which  causes  fermen- 
tation. 

The  poisonous  agents  capable  of  producing  inflammation  fall  naturally  into 
several  distinct  classes,  according  to  their  origin  and  nature:  (1)  the  mineral 
poisons;  (2)  those  elaborated  by  the  vital  chemistry  of  plants;  (3)  the  poison- 
ous secretions  of  animals ;  (4)  the  poisonous  infection  arising  from  the  action 
of  microscopic  cryptogamic  parasites;  and  (5)  putrid  substances. 

The  Poisonous  Action  of  Certain  Minerals — arsenicand  mercury,  for  example 
— gives  rise  to  inflammation  in  a  manner  quite  different  from  the  chemical  irri- 
tation produced  by  the  primary  contact  of  these  metals,  or  their  salts,  with 
the  living  tissues.  The  peculiar  nature  of  the  inflammation  is  generally  con- 
veyed by  the  use  of  the  term  specific,  and  its  action  is  only  developed  after 
the  mineral  poison  has  entered  the  blood-current  and  is  circulating,  to  all  ap- 
vol.  i. — 6 


82  INFLAMMATION-. 

pearance,  harmlessly  in  it,  when,  as  soon  as  the  ingestion  of  a  certain  amount 
has  been  reached,  an  active  gastric  hyperemia  attended  by  vomiting  super- 
venes, if  the  poison  be  arsenic,  or  an  inflammation  of  the  mouth  attended  by 
salivation,  if  the  poison  be  mercurial.  These  inflammatory  phenomena  may 
be  produced  with  equal  certainty  if  the  poisonous  substances  are  introduced 
into  the  blood-current  through  the  skin,  or  through  the  mucous  membrane  of 
the  rectum,  which  may  be  done  without  necessarily  producing  any  inflamma- 
tion of  either  absorbing  surface  ;  so  that  there  is  no  question  of  local  chemical 
irritation  from  direct  contact.  The  poisonous  action  upon  the  stomach,  or 
the  mouth,  is  something  different  from  that  produced  by  a  chemical  irritant, 
and  it  is  effected  by  a  different  mechanism;  it  is  "specific."  The  tissues  of 
the  stomach,  or  of  the  mouth,  are,  for  reasons  unknown  to  us,  more  sensitive 
to  the  action  of  these  mineral  poisons  than  the  tissues  of  other  organs;  and 
this  poisonous  action  manifests  itself  by  producing  the  phenomena  of  inflam- 
mation. The  renal  congestion  and  hematuria  which  result  from  persistent 
inhalation  of  volatilized  turpentine  is  readily  explained  by  the  irritating  action 
of  this  substance  upon  the  tissues  of  the  kidney  during  its  elimination  from 
the  blood,  and  the  same  mechanism  has  been  supposed  to  explain  the  desqua- 
mative nephritis  that  follows  scarlatina,  and  the  follicular  intestinal  ulcera- 
tion of  typhoid  fever.  I3ut  neither  arsenical  gastritis,  nor  mercurial  stoma- 
titis, has  been  accounted  for  in  this  way;  and  the  preferences  of  these  mineral 
poisons  for  certain  particular  organs  must  be  regarded,  for  the  present,  as 
ultimate  facts.  But  they  are  not  facts  without  parallel,  for  it  will  be  found 
hereafter  that  certain  septic  poisons,  when  they  gain  access  to  the  blood,  give 
rise  to  congestion  and  inflammation  of  serous  membranes,  and  at  certain  pre- 
ferred localities  of  the  intestinal  mucous  tract. 

Poisonous  Action  of  Plants.— -The  effect  of  the  contact  of  the  "stinging" 
nettle  (Urtica),  in  producing  a  papular  eruption,  of  the  poison  vine  (Rhus),  in 
causing  a  vesicular  irritation  of  the  skin,  of  croton  oil,  in  bringing  out  a  crop 
of  minute  abscesses,  are  familiar  examples  of  inflammation  resulting  from  the 
simple  contact  of  substances  of  vegetable  origin.  A  search  for  the  explana- 
tion of  these  phenomena  leads  us  also  to  the  ultimate  fact  that  these  sub- 
stances are  in  some  way  hostile  to  textural  life  or  well-being,  and  that  their 
contact,  probably  through  some  injurious  influence  exerted  upon  the  nerves 
of  the  locality,  temporarily  perverts  or  arrests  the  nutritive  process. 

Poisonous  Secretions  of  Animals. — Under  the  third  class — of  poisonous  secre- 
tions elaborated  in  the  living  animal  body — we  have  positive  clinical  evidence 
that  inflammatory  action  may  be  directly  excited  by  the  contact  of  pus,  or  of 
other  products  of  pre-existing  inflammation,  that  is  of  simple,  non-specific  in- 
flammation,  in  the  products  of  which  there  is  no  suspicion  of  the  presence  of 
extraneous  poisonous  matter  derived  from  any  other  source.  The  contagious 
quality  of  so-called  healthy  pus,  taking  this  secretion  as  a  typical  product  of 
inflammation,  is,  at  the  present  day,  so  generally  admitted  to  exist,  within 
certain  limits,  that  we  may  dispense  with  a  formal  demonstration  of  the  fact. 
The  evidence  collected  by  Simon,  who  contended  for  its  existence  in  I860,1 
showing  that  in  examples  of  inflammation  attributed  to  sympathy,  the  inflam- 
mation is  in  reality  due  to  the  contagious  quality  of  pus  ;  and  the  more  recent 
researches  of  Chauveau2  and  others,  leave  nothing  to  be  desired  in  the  way  of 
confirmation  of  the  fact.     As  to  the  nature  and  quality  of  the  inflammation 

•  Holmes's  System  of  Surgery,  1st  ed.,  18G0,  vol.  i.  p.  68  ;  id.  op.  2d  ed.  1870,  vol.  i.  p.  46. 
8  Revue  des  Cours  Scientifiques,  2eserie,  lr0  auntie,  14  et  21  Octobre,  1871  ;  2C  anuee,  13,  20,  et 
21  Juillet,  1872. 


CAUSES    OF   INFLAMMATION.  83 

thus  incited,  we  will  speak  farther  under  the  head  of  "  varieties"  of  inflam- 
mation ;  but  it  is  as  well  to  remark  here  that  although  the  subcutaneous  in- 
jection of  pus  in  the  lower  animals  is  capable  of  inducing  febrile  action  of  the 
simple  inflammatory  type,  with  great  certainty,  the  fever  thus  produced,  as  a 
rule,  subsides  spontaneously  ;  and  the  local  inflammations  excited  by  the  con- 
tact of  inflammatory  products,  when  the  latter  are  fresh  and  unmixed  v\ith 
other  sources  of  poison,  are,  for  the  most  part,  of  the  simple  catarrhal  variety, 
and  neither  unhealthy  nor  destructive.1  The  practice  of  inoculating  pawn  us  of 
the  conjunctiva  and  cornea  with  fresh  pus  to  provoke  inflammation  for  a 
curative  purpose,  employed  on  a  large  scale  in  Germany,  illustrates  at  the 
same  time  the  contagiousness  of  fresh  healthy  pus,  and  the  comparative  harin- 
lessness,  in  a  general  way,  of  the  inflammation  thus  excited. 

The  poisonous  qualities  of  certain  living  insects,  not  to  speak  of  dead  insects 
such  as  cantharides,  find  their  most  common  examples  in  the  Inosquito,  the 
bee,  the  wasp,  etc.  The  introduction  of  the  poison  of  the  mosquito  into  the 
substance  of  the  skin  of  a  person  who  has  not  acquired  an  immunity  from  its 
action,  is  followed  within  a  few  minutes  by  all  the  cardinal  symptoms  of  in- 
flammation in  miniature.  The  pain  takes  the  form  of  itching;  the  redness 
forms  a  well-marked  areola  produced  by  the  afflux  of  blood  from  every  direc- 
tion , towards  the  point  of  puncture — with  an  appreciable  increase  of  local 
heat;  and  the  swelling,  from  rapid  exudation,  is  often  so  tensive  as  to  arrest 
the  capillary  circulation  at  the  centre  of  the  affected  area  by  its  pressure, 
causing  a  distinctly  pallid  spot,  or  wheal,  at  its  apex.  After  a  short  time  all 
these  symptoms  disappear,  leaving  a  point  of  ecchymosis,  recognizable  with 
difficulty  on  account  of  its  minuteness.  This  gradual  and  entire  disappear- 
ance of  the  symptoms  of  inflammation  affords  an  example  of  the  phenomenon 
generally  described  as  "delitescence"  or  "resolution."  Isot  unfrequently  a  little 
thickening  of  the  tissues  remains  at  the  seat  of  the  injury  just  described,  and, 
from  time  to  time,  a  slighter  degree  of  itching  may  recur.  In  persons  of  an 
irritable  habit  an  ulcer  may  possibly  be  established  by  the  repeated  scratching 
thus  provoked.  There  is,  in  fact,  a  certain  amount  of  persistent  impairment 
or  degradation  of  vital  quality  incurred  by  the  nerves  and  other  textural  con- 
stituents of  a  part  by  the  contact  of  an  animal  poison — which  is  a  noteworthy 
characteristic  of  this  form  of  injury.  The  apparent  reluctance  to  heal,  and 
the  tendency  to  ulceration,  manifested  in  some  cases  after  vaccination,  is  an 
example  of  the  effects  of  local  tissue  poisoning ;  and  the  same  phenomena  are 
still  more  frequently  noticeable  in  the  behavior  of  the  contagious  venereal 
ulcer  usually  called  "chancroid."  Thus  the  lesson  is  to  be  learned  from  so 
trifling  a  poisoned  wound  as  a  "mosquito  bite,"' that  a  poison  is  a  noxious 
agent  capable  not  only  of  directly  exciting  the  condition  of  inflammation  in 
our  tissues,  to  a  degree  of  intensity  apparently  out  of  all  proportion  to  the 
injury  as  regards  its  magnitude  or  gravity,  but,  also,  of  leaving  after  it  a 
more  or  less  permanently  damaging  effect  upon  those  tissues,  by  which  their 
vital  quality  is  invalidated. 

In  addition  to  the  general  conclusion  that  this  source  of  injury  is  competent 
to  cause  a  local  derangement  of  the  nutritive  machinery,  which  manifests  itself 
by  the  phenomena  of  inflammation,  it  may  be  remarked  that  this  development 
of  the  inflammatory  condition  has,  apparently,  no  reparative  purpose.  It  is 
an  extravagant  outbreak,  on  a  limited  scale,  of  excessive  action  on  the  part 
of  the  local  nutritive  apparatus,  by  which,  as  far  as  we  can  see,  no  object  is 

1  Simon  concludes  "that  the  contagiousness  of  communicable  inflammation  seems  to  he  in 
some  special  way  relative  to  corpuscular  development,  and  the  contagium  to  he  inherent  in  grow- 
ing forms  ;  whereas,  the  contagiousness  of  the  specific  inflammation  seems  rather  rela'ive  to  their 
destructive  acts,  and  the  contagium  to  reside  in  defunct  and  dissolving  organic  compounds." 
(Loc.  cit.  ed.  1870,  p.  51.) 


84  INFLAMMATION. 

to  be  attained.  Heretofore,  the  inflammatory  changes  provoked  by  the  ox- 
citing  causes  which  have  been  under  consideration,  have  had  an  unmistakable 
purpose,  namely,  of  healing  a  breach  of  continuity,  or  of  getting  rid  of  a 
foreign  body ;  and  when  this  purpose  was  attained,  the  abnormally  excited 
nutritive  action  subsided.  But  in  the  examples  of  inflammation  provoked 
by  poisonous  contact  or  influence,  there  has  been  no  such  object  discernible — 
either  reparative  or  eliminative — as  far  as  we  have  evidence.  The  honey  bee, 
we  are  told  by  Huber,  often  leaves  his  serrated  weapon  in  the  little  wound 
through  which  the  poison  has  been  injected  in  the  act  of  stinging;  and  here 
a  foreign  body  is  to  be  got  rid  of;  but  there  is  no  such  cause  for  eliminative 
inflammation  apparent  in  the  "mosquito  bite."  We  may  adopt  the  additional 
conclusion,  therefore,  that  a  poison,  as  an  excitor  of  inflammation,  possesses  a 
novel  injurious  quality  as  regards  the  tissues — something  superadded  to  the 
cutting,  crushing,  or  burning  of  the  mechanical  and  chemical  lesions — the 
essential  nature  of  which  eludes  our  grasp.  We  are  compelled  to  characterize 
this  noxious  quality  by  its  effects  upon  the  nerves  and  bloodvessels  of  a  part, 
and  we  therefore  speak  of  the  part  as  poisoned. 

The  poisoned  condition  is  a  local  manifestation  of  the  same  nature  as  the 
more  general  influence  upon  the  nervous  centres  already  attributed  to  this 
class  of  injurious  agents.  Prof.  Agnew  gives  an  example  of  this  poisonous 
influence  in  a  case  in  which  it  followed  a  wound  inflicted  by  a  centipede,  a 
poisonous  myriapod  common  in  warmer  regions,  "sometimes  brought  to 
Eastern  cities  concealed  in  hogsheads  of  sugar.  I  have  seen,"  says  he,  "a 
stevedore  suffer  for  weeks  from  violent  local  and  constitutional  symptoms  in 
consequence  of  a  sting  received  on  the  hand  while  handling  one  of  these  hogs- 
heads on  the  wharf.  The  fingers  remained  purple,  and  the  hand  and  arm 
weak,  for  a  long  time.  His  general  health  was  seriously  impaired  by  the  in- 
jury;  and  when  I  last  saw  him  he  looked  like  a  man  who  had  passed  through 
a  tedious  and  wasting  spell  of  sickness."1  Within  the  experience  of  the  writer, 
a  naval  officer  stung  by  one  of  these  insects  on  the  hip,  was  subject  for  a  num- 
ber of  years  to  an  annual  eruption  of  angry  papules  at  the  seat  of  the  poisoned 
wound. 

The  influence  of  the  poisoned  condition  upon  the  grade  of  inflammation 
developed  in  tissues  thus  affected  should  not  be  overlooked.  For  the  nerves 
and  capillaries  of  parts  thus  degraded  in  the  quality  of  their  vitality,  as  we 
have  already  shown  in  the  examples  of  delayed  healing  after  vaccination,  and 
the  sloughing  of  certain  venereal  ulcers,  do  not  respond  in  a  healthy  manner 
to  the  stimulus  to  repair.  Such  poisoned  tissues  manifest  a  distinct  tendency 
to  suppuration,  and  to  molecular  disintegration. 

Effects  upon  the  living  tissues  somewhat  similar,  but  far  more  serious  in 
degree,  are  produced  by  the  venom  of  the  poisonous  serp>ents.  The  more  active 
of  these  poisons,  when  introduced  into  the  circulation,  cause  death  quite 
promptly  by  the  direct  action  of  the  venom  upon  the  nervous  centres  and  the 
heart.  Singularly  enough,  the  full  noxious  influence  of  serpent  venom,  as  the 
researches  of  Weir  Mitchell  have  shown,  is  transitory.  Like  the  effects  of 
the  woorara,  it  lends  to  decline,  and,  after  a  certain  interval,  to  disappear.2 

In  tlie  cases  in  which  its  immediate  mortal  effect  has  been  escaped,  the  local 
influence  of  serpent  poison  upon  the  tissues  is  that  of  an  inflammation-} ad- 
ducing agent,  of  great  power.  The  local  symptoms  following  the  bite  of  a 
rattlesnake  are  intense  pain,  with  rapid  swelling  attended  by  surface  discolo- 
ration and  mottling.    Incisions  of  the  affected  part  give  issue  to  scrum,  colored 

1  Prin ciplcs  and  Practice  of  Surgery,  vol.  i.  p.  227.      Philadelphia,  1878. 

2  Researches  upon  tin-  Venom  of  the  Rattlesnake;  with  an  investigation  of  the  Anatomy  and 
Physiology  Of  the  organs  concerned.  Published  by  the  Smithsonian  Institution.  Washington, 
18U0. 


CAUSES    OF   INFLAMMATION.  85 

by  blood ;  the  physiological  condition  of  the  vascular  walls,  and  also  of  the 
blood  itself,  is  manifestly  altered  by  the  immediate  contact  of  the  poison,  the 
blood  giving  early  evidences  of  putridity.  There  is  a  strong  tendency  to  local 
gangrene.  When  this  form  of  danger  is  escaped — wholly,  or  partially — sup- 
puration in  the  connective  tissue  follows.  Tins  suppuration  is  diffuse  in  its 
character,  that  is,  it  tends  to  travel  along  the  planes  of  connective  tissue,  as  in 
phlegmonous  erysipelas,  without  limitation  by  organizing  barriers  of  granula- 
tion tissue,  the  poisoned  condition  of  the  tissues  preventing  their  formation. 
At  a  later  period,  when  these  barriers  form,  it  becomes  evident  that  the  in- 
tensity of  the  inflammation-producing  action  of  the  venom  has  become  less, 
and  that  the  reparative  grade  of  inflammation  has  established  itself  in  place 
of  the  destructive ;  in  other  words,  that  the  vital  nutritive  process  is  no  longer 
overpowered  by  the  influence  of  the  poison,  and  is  again  working  normally. 
In  a  case  of  rattlesnake  bite  (by  an  imported  snake),  reported  by  Sir  Everard 
Home,  the  victim,  having  escaped  the  earlier  effects  of  the  poison,  died  ex- 
hausted by  suppuration  in  the  third  week. 

This  clinical  evidence  shows  that  there  are  exciting  causes  capable  of  giving 
rise  to  the  inflammatory  condition  in  its  most  destructive  phases — causes 
more  intense  and  effective  than  any  heretofore  examined.  These  latter,  in- 
deed, might  have  been  regarded  as  exaggerated  examples  of  a  stimulus  to 
repair,  demanding,  simply,  an  increased  effort  in  nutritive  activity.  The 
former,  on  the  other  hand,  exert  a  directly  damaging  effect  upon  the  apparatus 
of  nutrition  itself,  threatening  extinction  of  textural  life;  and  it  is  only  after 
this  first  influence  has  been  recovered  from,  mainly  in  consequence  of  the 
evanescent  quality  of  the  noxious  agent,  that  the  reparative  act  comes  in  play. 

"What  it  interests  us  especially  to  learn  concerning  inflammation,  is,  whether 
there  is  any  essentially  destructive  quality  that  belongs  intrinsically  to  the 
condition ;  or  if  its  destructive  phases  are  always  traceable  to  the  influences 
by  which  it  has  been  excited.  This  question  is  important  in  view  of  its  direct 
bearing  upon  the  practical  subject  of  treatment.  If  the  nature  of  its  exciting 
cause  determines  in  any  degree  the  grade  of  the  inflammation,  we  cannot 
study  the  nature  and  mode  of  action  of  exciting  causes  too  closely.  More 
light  may  be  thrown  upon  this  question  by  observing  the  several  modes  in 
which  inflammation  is  produced  by  the  sources  of  poisonous  injury  yet  await- 
ing consideration. 

The  grosser  parasites,  mainly  of  an  animal  nature,  such  as  acari,  trichina?, 
echinococei,  lice  (as  in  the  disease  known  as  phtheiriasis),  and  intestinal  worms, 
produce  various  injurious  effects  upon  our  tissues  and  organs,  but  they  excite 
inflammation  only  incidentally  as  foreign  bodies.  They  are  mentioned  in  this 
connection  as  suggestive  of  the  liability  of  our  bodies  to  parasitic  invasion. 
It  is  the  mode  of  action  of  the  multiform  microscopic  fungi,  and  their  germs, 
that  affords  most  interest  to  the  surgeon,  because  there  is  reason  to  believe 
that  these  invisible  particles  of  organized  matter  are  competent  to  act  inju- 
riously by  direct  contact  with  the  tissues  when  exposed  in  wounds. 

The  germs  of  the  vibrio  septica — one  of  the  most  active  and  dangerous  of 
the  bacteria,  according  to  Pasteur — are  singularly  indestructible  by  extremes 
of  heat  and  cold,  and  by  most  of  the  powerful  chemical  agents ;  but  the 
organisms  into  which  they  develop,  under  favorable  circumstances,  are  not 
so  tenacious  of  life  ;  they  have  the  peculiarity  of  not  being  viable  when 
exposed  to  the  influence  of  free  oxygen.  Wherever  oxygen  has  no  access, 
they  germinate,  however,  with  inconceivable  rapidity,  supporting  life  by 
appropriating  from  the  animal  materials  by  which  they  are  surrounded — 
wound-fluids  and  granulating  surfaces,  for  example — the  sustenance  they 
require.  In  the  changes,  chemical  and  vital,  to  which  these  animal  materials 
are  subjected  in  the  struggle  for  existence  of  the  vibrios,  the  result  is  putre- 


86  INFLAMMATION. 

faction.     The  presence  of  the  vibrio  septica  begets  putrefaction  in  a  mod  in  in 
of  animal  matter  by  inducing  a  process  of  fermentation. 

It  is  asserted  that  the  vibrios  evolved  from  the  germ's  first  deposited  upon 
the  surface  of  a  wound,  die  from  exposure  to  the  oxygen  of  the  air,  and  afford 
a  protection  to  the  surviving  germs  beneath,  which  are  thus  enabled  to 
germinate  indefinitely.  In  the  chemico-vital  changes  incident  to  the  process 
of  putrefactive  fermentation  thus  begotten,  certain  poisonous  combinations 
are  formed.  These  are  designated  as  septic  poi 'sons,  and  they  are  regarded  as 
the  source  of  the  dangerous  diseases  which  take  their  origin  in  wounds. 
The  wound  diseases  thus  produced  comprise  all  the  unhealthy  and  destructive 
forms  of  local  wound  inflammations,  as  well  as  the  consequences  of  the  ab- 
sorption of  septic  poisons  into  the  general  circulation,  namely,  septicaemia 
and  pyaemia.  This  micro-organism,  the  vibrio  septica,  is  considered  to  act  as 
a  poison,  first,  by  spoiling  the  materials  provided  for  repair,  and  thus  inter- 
rupting the  constructive  process  in  a  wound ;  and,  second,  by  acting  as  a 
putrefactive  ferment  and  elaborating  septic  poisons  which  cause  the  subse- 
quent destructive  phenomena. ' 

These  are  the  facts  which  Pasteur  asserts  that  he  has  demonstrated,  and 
upon  them,  mainly,  Lister  has  based  his  antiseptic  method  of  treatment  for 
wounds,  believing  that  they  afford  an  adequate  explanation  of  the  mechanism 
by  which  destructive  inflammation  is  caused  by  the  agency  of  cryptogam ic 
parasites. 

The  apparent  success  which  has  followed  the  practical  application  of  the 
antiseptic  methods  in  surgery,  has  invested  these  micro-organisms  with  much 
interest,  and  at  the  present  time  they  are  the  subjects  of  patient  and  careful 
study  in  many  quarters.  Those  who  have  pursued  this  study  most  success- 
fully assert  that  there  are,  probably,  numerous  other  organisms  possessing 
poisonous  qualities,  each  of  which  has  its  own  peculiar  mode  of  action. 
This,  in  fact,  has  been  recently  demonstrated  by  Koch,  a  most  patient  and 
able  investigator,  whose  statements  are  singularly  lucid  and  apparently 
judicial  in  their  fairness.1  This  author,  premising  that  generalizations  of 
new  facts  frequently  lead  to  mistaken  conclusions,  insists  that,  in  the  study 
of  this  subject,  every  individual  infective  disease,  or  group  of  closely  allied 
diseases,  attributed  to  bacteria,  must  be  separately  investigated.  He  holds 
that  the  bacteria  capable  of  producing  disease  are  limited  in  number,  and 
that  these  pathogenic  bacteria  comprise  different  and  distinct  species  ;  that 
the  only  correct  practical  method  of  studying  such  bacteria  as  seem  capable 
of  producing  constant  noxious  results,  is  by  cultivation  "from  spore  to  spore." 
There  is  no  better  cultivation  apparatus  for  pathogenic  bacteria,  he  asserts, 
than  the  body  of  an  animal.  By  this  method,  and  the  employment  of  certain 
improved  optical  appliances  by  which  these  particles  which  border  on  the 
invisible  can  be  more  readily  and  certainly  recognized,  this  observer  avers 
that  he  lias  demonstrated  the  certain  existence  of  at  least  five  artificial  trau- 
matic infective  diseases.  These  are:  septicemia,  in  mice;  progressive  destruc- 
tion of  tissue  (gangrene),  in  mice;  spreading  abscess,  in  rabbits;  septicaemia,  in 
rabbits;  pymmia,  in  rabbits;  and,  partially,  en/sy?e£as,  in  rabbits.  His  investi- 
gations show,  also,  that  these  artificial  traumatic  infective  diseases,  both  as 
regards  their  origin  from  putrid  substances,  their  course,  and  the  results  of 
post-mortem  examinations,  bear  the  greatest  resemblance  to  human  traumatic 
infective  diseases. 

The   most    important   demonstrated   result   attained   by  Koch,  by   using 

1  Investigations  into  the  Etiology  of  Traumatic  Infective  Diseases.  By  Dr.  Robert  Koch 
(Wollstein).     Translated    l>y    W.    Watson   Cheyne,    F.R.C.S.      London,    The   New   Sydenham 

Society,  1880. 


CAUSES   OF   INFLAMMATION.  87 

staining  materials  with  an  improved  optical  apparatus,  is  the  discovery  of 
the  specific  differences  which  exist  between  pathogenic  bacteria  and  the 
constancy  of  their  characteristic  features,  not  only  as  to  form,  but  as  to  the 
nature  of  the  noxious  effect  produced  by  each.  "A  distinct  bacteric  form 
corresponds,"  as  he  says  in  his  conclusions,  "  to  each  disease,  and  this  form 
always  remains  the  same,  however  often  the  disease  is  transmitted  from  one 
animal  to  another."  In  regard  to  septicaemia,  he  says :  "I  have  performed 
these  experiments  on  fifty-four  mice,  and  always  obtained  the  same  result. 
.  .  .  Further,  when  we  succeed  in  reproducing  the  same  disease  de  novo 
by  the  injection  of  putrid  substances,  only  the  same  bacteric  form  occurs 
which  was  before  found  to  be  specific  for  that  disease." 

This  statement,  if  confirmed,  marks  an  important  advance  in  our  knowledge 
as  bearing  directly  upon  the  exciting  causes  of  destructive  inflammation. 
The  concluding  words  of  Dr.  Burdon  Sanderson's  "  Report  on  the  Causes  of 
Infective  Diseases,"  in  1875,  marked  the  limit  of  justifiable  assertion  at  that 
time.  "  If  these  infinitely  minute  organisms  are  present  in  every  intense 
infective  inflammation,"  says  Sanderson,  "  we  may  be  quite  sure  that  they 
stand  in  important  relation  to  the  morbid  process."  It  has  now  been  appar- 
ently demonstrated  that  these  organisms  are  present  in  every  intensely  infec- 
tive inflammation  thus  far  brought  under  sufficiently  close  investigation,  and 
that  they  are  not  present  in  normal  blood  when  tested  as  to  its  power  of 
causing  development  by  cultivation  methods,  excluding  all  sourees  of  error, 
by  Pasteur,  Burdon  Sanderson,  and  Klebs  ;*  that  they  bear  the  relation  to 
the  disease  following  their  inoculation  of  cause  to  effect ;  that  there  are 
different  and  distinct  species  of  noxious  bacteria;  and  that  a  positive  and 
constant  causal  relation  exists  between  certain  infective  diseases  and  distinct 
species  of  bacteria.  Dr.  Koch,  by  the  employment  of  his  improved  methods, 
has  arrived  at  a  conclusion  which  is  sufficiently  important  to  justify  repeti- 
tion— "  that  bacteria  do  not  occur  in  the  blood  nor  in  the  tissues  of  the  healthy 
living  body  either  of  man  or  of  the  lower  animals." 

One  of  the  novel  and  original  results  attained  by  this  observer  is  of  great 
interest.  By  the  aid  of  an  improved  optical  condenser  he  was  able  to  verify 
at  will  the  presence  of  exceedingly  minute  bacteria  of  the  species  bacillus,  but 
much  smaller  than  the  bacillus  anthracis,  in  the  blood  of  mice  artificially  in- 
oculated with  putrid  fluids,  and  dying,  invariably,  with  symptoms  of  septi- 
caemia. Along  with  this  bacillus  he  observed  in  the  neighborhood  of  the 
point  of  inoculation,  another  bacterium — a  micrococcus — characterized  by  a 
very  rapid  increase,  and  the  formation  of  regular  chains.  This  micrococcus 
was  never  present  in  the  blood.  When  a  healthy  mouse  was  inoculated  with 
the  blood  of  a  septicsemic  mouse,  only  the  septicsemic  bacilli  were  trans- 
mitted, and  these  were  invariably  found  in  the  blood  of  the  inoculated  animal ; 
but,  when  putrid  fluid  was  injected,  the  bacillus  was  always  found  in  the 
blood,  and  the  micrococcus  was  always  present  in  the  tissues  near  the  infected 
point — the  other  bacteria  contained  in  the  putrid  fluid,  and  injected  at  the 
same  time,  dying  out  promptly  because  they  did  not  find  in  the  tissues  of  the 
living  mouse  a  congenial  soil. 

By  studying  the  local  effect  of  the  micrococci  after  an  inoculation  in  the 
tissues  of  the  ear,  which  is  found  to  be  a  favorable  locality  for  observation,  it 
is  discovered  that  these  tissues  are  killed  by  their  contact,  and  even  by  their 
proximity.  In  the  tissues  thus  deprived  of  life,  the  parasitic  growth  is  seen 
to  multiply  and  spread  more  vigorously,  extending  itself  especially  towards 
living  parts.  As  it  advances,  all  of  a  sudden  a  densely  agglomerated  mass  of 
leucocytes  appears — 

1  Koch,  op.  cit.,  p.  14. 


88  INFLAMxMATION. 

" .  .  .  forming,  as  it  were,  a  wall  against  the  invasion  of  the  micrococci,  and  this  is 
the  limit  up  to  which  these  organisms  may  be  found.  They  do  not  extend,  even  in 
the  (dead)  bloodvessels,  beyond  this  line,  the  wall  of  nuclei  (leucocytes)  has  no  great 
breadth,  and  immediately  beyond  it  comes  the  normal  tissue.  By  the  aid  of  high 
magnifying  powers  it  becomes  apparent  that  the  micrococci  do  not  reach  quite  up  to  the 
nuclear  layer.  On  the  side  directed  towards  the  micrococci  the  nuclei  are  undergoing 
destruction.  .  .  .  There  almost  always  remains  between  the  last  remnants  of  the 
nuclei  and  the  micrococci  a  line  of  considerable  breadth,  consisting  only  of  gangrenous 
tissue,  in  which  neither  micrococci  nor  nuclei  can  be  found." 

Dr.  Koch  assumes  that  the  action  of  these  parasites  in  causing  this  spread- 
ing gangrene  is  somewhat  as  follows : — 

"  Introduced  by  inoculation  into  living  animal  tissues,  they  multiply,  and,  as  a  part 
of  their  vegetative  process,  they  excrete  soluble  substances,  which  get  into  the  surround- 
ing tissues  by  diffusion.  When  greatly  concentrated,  as  in  the  neighborhood  of  the 
micrococci,  this  product  of  the  organisms  has  such  a  deleterious  action  on  the  cells  that 
these  perish  and  finally  completely  disappear.  At  a  greater  distance  from  the  micro- 
cocci, the  poison  becomes  more  diluted,  and  acts  less  intensely,  only  producing  inflam- 
mation and  accumulation  of  lymph  corpuscles.  Thus  it  happens  that  the  micrococci 
are  always  found  in  the  gangrenous  tissue,  and  that  in  extending  they  are  preceded  by 
a  Avail  of  nuclei  which  constantly  melts  down  on  the  side  directed  towards  them,  while 
on  the  opposite  side  it  is  as  constantly  renewed  by  lymph  corpuscles   deposited  afresh." 

Various  efforts  were  made  to  isolate  these  parasites — the  minute  septicemic 
bacillus,  and  the  gangrene-producing  micrococcus — from  each  other,  so  as  to 
study  each  separately  by  cultivation  in  different  animals.  But  for  a  long  time 
the  efforts  did  not  avail. 

"  Either  pure  septicaemia,  or  septicemia  along  with  progressive  gangrene,  was  attained, 
never  the  latter  alone.  Chance  led  me  to  the  proper  method.  A  field  mouse — which, 
as  I  formerly  pointed  out,  possesses  an  immunity  from  septicaemia — was  inoculated  with 
septicemic  bacilli  and  chain-like  micrococci.  The  experiment  was  made  in  the  expec- 
tation that  neither  parasite  would  develop.  This  expectation,  however,  was  not  ful- 
filled, for,  although  the  bacilli,  as  usual,  underwent  no  development,  the  micrococci 
increased  and  spread  exactly  in  the  same  manner  as  has  been  described  in  the  case  of 
the  house-mouse.  Beginning  at  the  place  of  inoculation  on  the  root  of  the  tail,  the 
gangrene  spread  onwards  along  the  back,  passing  deeply  among  the  dorsal  muscles,  and 
downwards  on  both  sides  to  the  abdominal  wall.  The  animal  died  three  days  after  the 
inoculation.  The  parts  affected  with  the  gangrene  were  partially  denuded  of  epidermis 
and  hairs,  and  contained  chain-like  micrococci  in  extraordinary  numbers.  The  same 
micrococci  were  also  found  on  the  surface  of  the  abdominal  organs,  although  there  was 
no  visible  peritonitis.  The  blood  and  the  interior  of  the  organs  were,  on  the  other  hand, 
quite  free  from  them.  From  this  animal  other  field-mice,  and  from  these  again  house- 
mice  in  various  successive  series,  were  subsequently  injected,  and  always  with  the  like 
result,  viz.,  that  only  chain-like  micrococci  and,  in  their  train,  progressive  gangrene, 
were  obtained." 

The  ingenious  observer  who  is  responsible  for  these  statements  found 
equally  interesting  and  positive  results  on  investigating  the  spreading  cheesy 
abscesses  produced  by  putrid  subcutaneous  injections.  He  found  a  specific 
form  of  bacteric  vegetation,  proved  its  peculiar  qualities  by  cultivation,  and 
produced  the  same  artificial  infective  disease  at  will.  He  discovered  also 
another  distinct  variety  of  micrococcus  which  developed  habitually  in  blood- 
vessels, and  which  possessed  the  unique  quality  of  spinning  around  the  blood 
corpuscles  and  inclosing  them  so  as  to  beget  thrombosis  and  positive  embolism. 
The  Bame  growth  also  caused, by  its  contact,  purulent  (not  cheesy)  infiltration 
of  the  connective  tissue.  This  new  infective  material  was  also  propagated  by 
cultivation,  and  proved  competent- to  produce  pyemia,  at  will,  by  separate 
inoculation. 


CAUSES   OF   INFLAMMATION.  89 

These  results,  demonstrating  the  agency  of  bacteria  as  the  source  of  septic 
poisoning,  to  which,  in  searching  for  causes  competent  to  excite  the  phe- 
nomena of  destructive  inflammation,  we  must  give  due  consideration,  have 
certainly  much  weight  as  evidence  in  favor  of  the  antiseptic  method  of  treat- 
ing wounds.  They  are  in  accord  with  previous  advances  in  the  same  direc- 
tion. The  connection  of  the  bacillus  anthracis  with  malignant  pustule,  and  of 
the  spirilla  with  relapsing' fever,  in  man,  established  on  the  evidence  of  reliable 
observers,  is  generally  received.  It  is  a  matter  of  recent  history  that  the 
theory  on  which  Lister  based  his  antiseptic  method,  first  promulgated  in 
1866-67,  encountered,  at  first,  very  general  scepticism.  It  has  been  followed 
by  results,  even  in  the  hands  of  many  who  tried  the  method  in  practice  with- 
out accepting  the  theory  on  which  it  was  based,  which,  by  their  apparent 
confirmation  of  the  theory,  have  led  to  a  wider  acceptance  of  its  scientific 
truth.  The  results  of  the  experiments  on  animals  just  quoted  are  of  a  nature 
to  strengthen  this  belief. 

It  may  seem  out  of  place  in  this  connection  to  speak  of  the  practical  re- 
sults of  antiseptic  surgery,  but,  in  the  present  attitude  of  this  important 
question,  the  most  available  evidence  as  to  the  truth  of  the  theory  is  furnished 
by  the  very  considerable  degree  of  success  which  has  been  attained  by  the 
antiseptic  method  of  treatment.  In  striving  to  reach  a  correct  estimate  of 
micro-organisms  as  exciting  causes  of  destructive  inflammation,  it  is  proper, 
therefore,  to  recognize  that  clinical  experience  tends  to  prove  that  the  means 
which  have  been  found  hostile  to  the  development  of  these  organisms,  are  also 
growing  steadily  in  reputation  as  remedies  for  the  destructive  phases  of  in- 
flammation. 

Beyond  these  exciting  causes  of  destructive  inflammation,  what  others  offer 
themselves  as  worthy  of  serious  eonsideration  ?  Amongst  the  causes  hereto- 
fore examined,  the  most  worthy  of  notice  in  this  connection  are  persistent 
local  irritation  from  mechanical  causes,  and  constant  motion  of  an  injured 
part,  or  the  absence  of  the  degree  of  quiescence  necessary  for  the  successful 
accomplishment  of  constructive  repair.  Hospital  patients  have  been  known 
to  apply  irritating  powders — as  of  cantharides — to  their  ulcers,  with  the 
purpose  of  preventing  their  healing,  and  of  delaying  the  time  of  their  dis- 
charge from  what  they  found  comfortable  quarters.  But  hindrances  to  heal- 
ing of  this  character  cease  to  act  as  such  as  soon  as  they  are  withdrawn, 
unless  the  predispositions  of  the  patient  are  exceptionally  unfavorable. 

Surgical  pathologists  have  heretofore  sought  for  an  explanation  of  wound 
diseases  and  wound  infection  in  poisons  generated  under  the  circumstances  of 
disturbed  nutritive  effort  incident  to  every  wound,  and  their  formation  has 
been  ascribed  to  the  decomposition  and  recomposition  taking  place,  under 
these  circumstances,  in  the  unstable  albuminous  compounds  forming  the  fluids 
of  a  wound.  Robin  has  asserted  that  poisons  of  great  virulence  may  be  thus 
generated  without  the  intervention  of  micro-organisms,  basing  the  opinion 
upon  the  purely  chemico-vital  origin  of  the  potent  serpent  venom.1  In  ac- 
cordance with  this  view,  Billroth  of  Vienna  formed  his  hypothesis  of  the 
generation  in  the  fluids  of  a  recent  wound  of  a  "phlogistic  zymoid" — a 
something  capable  of  causing  destructive  inflammation,  which  acts  like  a 
ferment;  and  Verneuil,  of  Paris,  suggested  the  theory  of  the  formation  of  a 
"traumatic  virus,"  by  which  deviations  from  the  healthy  process  of  repair  of 
wounds  is  to  be  explained.  Lister,  of  London,  adopting  Pasteur's  views  as 
to  the  agency  of  micro-organisms,  finds  a  phlogistic  zymoid  in  the  conse- 

1  According  to  Mitchell  the  pure  rattlesnake  venom  when  freshly  ejected  contained  no  figured 
elements  whatever.  (Ut  supra.) 


90  INFLAMMATION. 

quences  of  the  struggle  for  life  of  the  product  of  aerial  germs.  The  position 
of  Lister  is  less  assailable  because  lie  has  found  means  of  destroying  the 
vitality  of  the  germs  and  of  protecting  wounds  from  their  septic  action,  as- 
serting, and  demonstrating,  that  it  is  in  the  power  of  surgery  to  preserve  a 
wound  in  an  absolutely  aseptic  condition,  and  to  protect  the  process  of  repair 
from  interruption  or  complication  by  intrinsic  causes.  For  the  soluble  poisons 
of  chemical  origin,  no  such  antidote  has  been  found. 

As  regards  wound  infection,  the  gross  results  furnished  by  clinical  exped- 
ience prove  that  subcutaneous  wounds,  and  those  which  heal  under  a  seal), 
and  wounds  protected  by  antiseptic  dressing,  are  infinitely  more  secure  from 
interruption  of  the  simple  process  of  repair  than  wounds  which  are  not  thus 
protected  from  the  external  air.  The  most  probable  explanation  of  this 
immunity  from  injurious  complications  is  the  exclusion  of  noxious  organisms 
floating  in  the  air.  The  converse  of  this  proposition,  that  the  unhealthy  and 
destructive  phases  of  the  inflammatory  process  are  directly  due  to  contami- 
nation by  these  omnipresent  aerial  organisms,  seems  also  for  the  far  greater 
proportion  of  cases  infinitely  probable ;  but  it  awaits  final  confirmation. 
Before  the  recent  discoveries  of  Pasteur  and  Koch,  the  antiseptic  theory  pre- 
sented a  sufficient  basis  of  probability  to  have  secured  its  acceptance  by 
trained  observers.  Witness  the  evidence  of  Professor  Tyndall  as  to  the  cause 
of  the  ill  behavior  of  an  abrasion  of  the  leg  which  befell  him  on  an  Alpine 
expedition,  and  the  experiments  detailed  in  his  paper  on  "  Dust  and  Dis- 
ease -,"1  witness  the  recorded  experience  of  practical  surgeons  in  all  parts  of 
the  world,  to  be  found  in  current  medical  journals.  Of  these  latter  witnesses, 
a  certain  proportion  testify  with  reserve,  and  strive,  in  the  true  spirit  of 
scientific  skepticism,  to  explain  their  confessedly  greater  success  otherwise 
than  by  the  exclusion  of  poisonous  germs.  This  success  has  been  attributed 
accordingly  to  improvements  in  hospital  hygiene,  to  the  isolation  of  cases,  to 
the  observance  of  scrupulous  cleanliness  in  dressings,  and  to  more  intelligent 
and  careful  nursing — all  of  which  would  rationally  conduce  to  a  greater 
degree  of  success  in  the  treatment  of  surgical  cases. 

Put  evidence  such  as  that  furnished  by  Nussbaum,  of  Munich,  is  more 
positive  in  its  character.  This  eminent  surgeon  testifies  that  pyaemia  and 
hospital  gangrene,  which  had  been  prevalent  in  his  hospital  wards  for  years, 
disappeared  as  soon  as  the  antiseptic  method  of  dressing  wounds  had  been 
adopted,  without  any  other  material  change  as  to  the  surroundings  and 
nursing  of  his  patients.  Similar  testimony  has  been  given  by  many  other 
hospital  surgeons  in  Germany  ;  and  more  recently,  after  noticeable  reluctance 
and  some  ridicule  of,  the  new  method,  we  have  evidence  that  it  has  been 
seriously  adopted  in  France,  and  the  greater  success  following  its  use  has 
been  acknowledged  by  prominent  Parisian  hospital  surgeons.2 

The  noxious  influence  of  putrid  substances,  animal  or  vegetable,  and  their 
power  when  introduced  amongst  living  tissues  of  producing  various  phases 
of  destructive  inflammation,  has  been  long  known,  but  the  evidence  as  to 
their  mode  of  action  has  been  heretofore  obscure,  and  even  in  some  respects 
contradictory.  The  directly  depressing  effects  of  putrid  exhalations  upon 
the  nervous  centres,  as  proved  by  the  nausea  they  produce,  is  due  mainly  to 
the  hydro-sulphuric  acid  gas  which  is  always  present,  Its  action  is  some- 
what like  thai  of  hydrocyanic  acid,  but  less  intense.  Bernard  injected  this 
gas  into  the  veins  of  a  dog  with  the  effect  of  causing  utter  prostration;  but 

'  Fragments  of  Science  for  Unscientific  People.     London,  1871. 

2  Chirurgie  antiseptique,  etc.  Par  J.  Luoas-Championniere.  Paris,  1880.  It  seems  proper  to: give 
due  consideration  to  these  incidents  of  current  history  in  attempting,  at  the  present  time,  to  form 
a  just  estimate  of  the  degree  of  importance  of  cryptogamic  organisms  as  causes  of  the  more  grave 
forms  of  inflammation. 


CAUSES   OF   INFLAMMATION.  91 

after  a  short  time  the  symptoms  of  poisoning  passed  away,  and  the  discolora- 
tion of  a  sheet  of  white  paper  saturated  with  a  solution  of  a  salt  of  lead  and 
held  before  the  nostrils  of  the  animal,  showed  that  the  gas  was  being  elimi- 
nated from  the  blood,  through  the  lungs.  There  is  no  evidence  that  any 
phlogogenic  power  is  exerted  by  this  gas  which  so  constantly  accompanies 
putrefaction. 

The  notoriously  dangerous  effects  which  are  liable  to  follow  inoculation 
with  the  fluids  of  a  recently  dead  body,  as  exemplified  in  wounds  received 
in  post-mortem  examinations,  have  been  ascribed  to  a  poison  formed  by 
chemical  action  taking  place  just  before  or  just  after  death.  It  is  proved 
by  experience  that  wounds  received  in  examination  of  recently  dead  bodies, 
are  more  likely  to  be  serious  in  their  poisonous  effects  than  those  received 
after  decomposition  has  set  in.  Hence  the  assertion,  formulated  by  Robin, 
that  putrefaction  destroys  animal  poisons.  Nevertheless,  according  to  Mitchell, 
the  venom  of  the  rattlesnake,  a  typical  animal  poison,  is  equally  deadly  and 
characteristic  in  its  action  after  it  has  been  kept  for  weeks  and  has  become 
"  horribly  offensive"  and  full  of  living  organisms,  as  when  perfectly  fresh 
and  containing,  as  he  asserts,  no  figured  elements  whatever. 

This  leads  to  the  question,  which  has  been  so  much  disputed,  as  to  the 
nature  of  the  putrid  poison — Whether  it  is  a  soluble  substance  of  chemical 
origin,  or  whether  its  poisonous  qualities  are  due  to  the  presence  of  living 
organisms?  The  much-quoted  researches  of  Bergmann,  and  more  recently 
of  Panum,  affirm  the  existence  in  putrid  matters  of  a  soluble  substance  of  the 
nature  of  an  alkaloid  active  principle,  to  which  the  name  of  sepsin  has  been 
given;  and  the  validity  of  this  conclusion  has  not  been  successfully  disputed. 
But  the  still  more  recent  researches  of  Pasteur,  of  Burdon  Sanderson — into 
the  nature  of  the  cause  of  infective  inflammation — and  latterly  of  Koch,  justify 
the  belief  that  bacteria  of  many  species — some  of  which  are  noxious  and 
phlogogenic,  some  doubtful,  and  others  entirely  innocent — are  also  to  be 
found  in  all  putrid  substances.  At  the  present  time,  therefore,  we  must 
admit  that  putrid  substances  contain  both  chemical  and  bacteric  sources  of 
poisonous  action. 

In  the  well-known  experiments  of  Dr.  Anders,  of  Dorpat,1  in  which  he 
showed  that  complete  destruction  of  the  organisms  in  a  liquid  which  had  been 
proved  to  be  septic,  in  no  way  impaired  its  virulent  action,  the  conclusion 
Avas  to  all  appearances  indisputable.  Although  the  bacteria  were  removed 
from  the  virulent  putrescent  fluid  by  filtration  through  porcelain — a  method 
not  absolutely  certain — yet  no  evidences  of  bacteric  life  could  afterwards  be 
disrovered  in  it  by  the  cultivation  test,  that  is,  by  adding  a  drop  of  the  filtered 
fluid  to  Pasteur's  or  any  solution  offering  congenial  soil.  But  these  experi- 
ments are  not  final ;  the  bacteria  before  their  removal  may,  as  a  part  of  their 
vegetative  process,  have  excreted  certain  soluble  sul  (stances  of  a  poisonous 
nature  which  remained  in  the  filtered  solution.  Such  sul  (stances,  tor  exam- 
ple, as  were  diffused  into  the  surrounding  tissues  by  the  gangrene-producing 
micrococcus  discovered  by  Koch.2 

The  latter  observer  evidently  recognizes  the  presence  of  poisonous  agents  of 
both  chemical  and  bacteric  origin  in  putrid  fluids.  In  his  researches  under- 
taken to  test  the  correctness  of  the  conclusions  of  Coze,  Felt/,  and  Davaine, 
putrid  fluids,  e.  g.,  putrefying  blood,  putrid  meat  infusion,  etc.,  were  injected 
under  the  skin  in  mice. 

"  The  result  of  such  an  injection,"  he  says,  "  differs  much  according  to*the  nature  of 
the  putrid  fluid,  and  according  to  the  quantity  which  is  introduced.      Blood  and  meat 

'  Detailed  in  the  first  article  in  the  seventh  volume  of  the  Deutsche  Zeitschrift  ftlr  Chirurgie. 
2  Op.  cit.,  p.  42. 


92  INFLAMMATION. 

infusion,  which  have  putrefied  for  a  long  time,  appear  to  act  less  injuriously  than  fluids 
which  have  putrefied  for  a  few  days  only.  Of  these  latter  fluids,  as,  for  instance,  of 
blood  which  has  not  putrefied  too  long,  five  drops  is  sufficient  to  kill  a  mouse  within  a 
short  time.  In  this  case  marked  symptoms  may  be  observed  in  the  animal  immediately 
after  the  injection.  It  becomes  restless,  running  about  constantly,  but  showing  great 
weakness  and  uncertainty  in  all  its  movements  ;  it  refuses  food,  the  respiration  becomes 
irregular  and  slow,  and  death  takes  place  in  four  to  eight  hours.  In  such  a  case  the 
greater  part  of  the  fluid  injected  is  found  in  the  subcutaneous  cellular  tissue  of  the  back 
in  much  the  same  condition  as  before  it  was  injected.  It  contains  bacteria  of  the  most 
diverse  forms,  irregularly  mixed  together,  and  as  numerous  as  when  examined  before 
injection.  No  inflammation  can  be  observed  in  the  neighborhood  of  the  place  of  injec- 
tion. The  internal  organs  are  also  unaltered.  If  blood  taken  from  the  right  auricle  be 
introduced  into  another  mouse  no  effect  is  produced.  Bacteria  cannot  be  found  in  any 
of  the  internal  organs,  nor  in  the  blood  of  the  heart.  An  infective  disease  has,  there- 
fore, not  been  produced  as  the  result  of  the  injection.  On  the  other  hand,  there  can  be 
no  doubt  that  the  death  of  the  animal  was  due  to  the  soluble  poison,  sepsin,  which  has 
been  shown  by  the  researches  of  Bergmann,  Panum,  and  various  other  investigators,  to 
exist  in  putrid  blood.  The  animal  has  accordingly  died  not  from  an  infective  disease, 
but  simply  from  the  effects  of  a  chemical  poison." 

This  poison  is,  apparently,  of  the  same  nature  as  serpent  venom,  producing 
its  deadly  effect  in  a  few  hours  by  acting  directly  upon  the  nervous  centres, 
without  the  intervention  of  bacteria.  Subsequently  when,  in  other  experi- 
ments, a  smaller  dose  of  the  putrid  fluid  was  injected  under  the  skin  of  a 
mouse,  the  symptoms  made  their  appearance  more  slowly,  and  they  were 
strikingly  different  in  character,  causing  death  in  from  forty  to  sixty  hours, 
instead  of  from  four  to  eight.  Here  the  symptoms  were  evidently  those  of  an 
infective  disease,  for  the  blood  was  found  swarming  with  bacteria.  "When 
the  blood  of  a  mouse  dying  in  this  way  was  injected  under  the  skin  of  a 
healthy  mouse,  death  followed  with  precisely  the  same  symptoms,  namely, 
those  of  septicaemia.  So  that  we  are  justified  in  concluding  from  these  ex- 
periments that  inoculation  with  putrid  fluids  may  produce  poisonous  effects 
by  a  soluble  chemico-vital  poison  analogous  to  serpent  venom,  acting  in  its 
peculiar  way;  and,  also,  by  the  slower  action  of  living  organisms,  acting  in 
an  entirely  different  way. 

Modes  in  which  Poisons  are  Absorbed. — It  is  proper  that,  as  surgeons,  we 
should  be  familiar  with  the  modes  by  which  the  poisons  last  under  considera- 
tion gain  access  to  the  organism,  with  the  view  of  possibly  averting  or  pre- 
venting their  effects.  The  human  body  enjoys  a  certain  conservative  protec- 
tion against  the  influence  of  noxious  agents.  The  action  of  all  poisons  is 
incidental  and  exceptional,  and,  it  maybe  assumed,  preventible,  by  the  use  of 
intelligence  to  supplement  these  conservative  means.  Foremost  amongst  them 
is  the  phenomenon  of  life  itself,  which  has  been  defined  as  the  power  of  resist- 
ing the  tendency  to  chemical  decomposition.  It  is  matter  of  general  belief 
that  diminished  vitality  from  any  cause  invites  the  invasion,  and  favors  the 
development  of  parasites;  and  that  the  healthy  and  robust  are  more  likely  to 
ivsi>t  causes  of  disease.  Whilst  this  may  be  the  rule,  there  are  frequent  ex- 
ceptions  to  it.  These  exceptions  arise  from  personal  peculiarities  conferring 
immunity,  or  from  other  conditions  not  yet  within  our  grasp,  which  enable 
the  organism  to  resist  causes  of  disease  at  one  time,  Avhilst  at  another  time 
it  yields  unaccountably  to  the  same  poisonous  influences.  Thus,  the  man 
who  habitually  handles  dead  bodies,  as  in  the  dissecting  room,  often  enjoys 
excellenl  health,  and  the  pathologist,  in  the  daily  habit  of  making  post-mor- 
tem examinations,  acquires  an  immunity  from  poisons  derived  from  this 
source,  which  could  not  be  counted  on  by  another  individual,  even  in  appa- 
rently better  physical  condition,  and  perhaps, fresh  from  country  life. 


CAUSES   OF   INFLAMMATION.  93 

The  main  avenue  through  which  absorption  of  extraneous  materials  into 
the  blood  takes  place  is,  as  in  the  process  of  nutrition  by  food,  the  lymphatic 
vessels.  Absorption  may  also  occur  through  the  walls  of  the  bloodvessels. 
The  epidermis  is  provided  for  the  protection  of  the  external  surface  of  the 
body,  and  usually  prevents  absorption  through  the  skin;  but  not  under  all 
circumstances.  Substances,  like  mercurial  ointment,  which  may  be  possibly 
forced  by  friction  into  the  open  mouths  of  the  sweat  ducts,  are  very  certainly 
absorbed,  as  proved  by  the  specific  action  of  the  drug  which  is  constantly  pro- 
duced in  this  way.  The  same  result  undoubtedly  follows  baths  containing 
corrosive  sublimate  in  solution.  Some  of  the  subtle  poisons  lately  under  con- 
sideration may  penetrate  the  unbroken  cuticle,  and,  thus  gaining  access'to  the 
blood,  give  rise  to  infective  diseases.  This  occurred  to  the  eminent  English 
surgeon,  Sir  James  Paget,  who  suffered  from  spreading  inflammation  of  the 
cellular  tissue  extending  to  the  trunk  and  resulting  in  abscess,  from  which 
he  barely  escaped  with  his  life  after  three  months'  illness.  He  gives  a  detailed 
account  of  his  own  case,1  and  attributes  his  illness  to  infection  by  a  material 
absorbed  from  the  dead  body  of  a  patient  who  had  died  from  pleuritic  effu- 
sion and  pysemia  after  lithotomy.  During  the  post-mortem  examination,  the 
surgeon's  hands  were  long  soaked  in  the  pleuritic  fluid.  He  says :  "What- 
ever the  virus  was,  it  soaked  through  my  skin  ;  I  had  no  wound  or  crack  of 
any  kind." 

This  is  an  exceptional  case,  as  the  epidermis,  when  unbroken,  is  usually 
an  efficient  protection.  ISTevertheless,  as  we  have  seen,  the  simple  contact  of 
a  "  poison  vine"  will,  with  many  persons,  cause  a  crop  of  vesicles.  But,  as  a 
rule,  a  puncture,  however  slight,  or  an  abrasion,  is  present,  and  this  offers  an 
avenue  of  entrance  to  the  poison.  In  the  case  of  the  late  Dr.  Hayward,  of 
Boston,  described  also  by  himself,2  he  simply  touched  the  mucous  surface  of 
the  intestine  to  determine  the  existence  of  ulceration,  at  the  post-mortem 
examination  of  a  child  dead  from  tubercular  meningitis,  and  afterwards 
pricked  his  finger  slightly  in  aiding  to  sew  up  the  body,  and  within  the  week 
his  finger  had  become  gangrenous.  Lawrence3  details  the  case  of  a  surgeon 
who  died  after  similar  infection,  and  who  was  not  conscious  of  any  lesion 
whatever  until  he  discovered,  by  the  aid  of  a  magnifying  lens,  a  minute 
puncture  of  the  finger  at  a  point  which  had  become  painful. 

An  abrasion  of  the  male  genital  organ  is  a  recognized  avenue  of  entrance 
of  the  syphilitic  virus;  and  a  crack  of  the  lip,  in  a  healthy  person,  may  become 
the  seat  of  an  infecting  chancre,  through  inoculation  by  the  saliva  of  another 
person  who  has  the  secondary  mucous  patches  of  syphilis  upon  the  mucous 
membrane  of  the  mouth.  The  mode  in  which  absorption  is  effected  in  these 
cases,  is  no  doubt  through  the  open  orifices  of  the  minute  lymphatic  canaliculi 
of  the  integument ;  although  it  may  take  place  through  the  walls  of  capillary 
bloodvessels,  even  when  they  are  free  from  lesion.  The  absorption  of  the 
vaccine  virus  after  partially  scratching  away  the  epidermis  is  a  familiar 
example.  The  epithelium  of  mucous  membranes  is  inferior  to  epidermis  as 
a  protective.  ]N"evertheless,  the  pavement  epithelium  of  the  mouth  being 
sound,  it  has  proved  safe  to  suck  the  venom  from  a  serpent  wound.  Virulent 
substances  undoubtedly  become  lodged  in  the  minute  mucous  follicles,  and 
are  subsecniently  absorbed. 

In  subcutaneous  injections,  as  of  morphine,  absorption  is  accomplished  by 
the  lymphatic  canaliculi  which  open  upon  the  surfaces  of  the  connective 
tissue  meshes.  This  method  is  usually  employed  in  introducing  putrid 
poisons  into  the  bodies  of  the  lower  animals ;  but  in  many  of  Koch's  experi- 

1  Clinical  Lectures  and  Essays,  2d  edition,  page  320.     London,  1879. 

2  American  Journal  of  the  Medical  Sciences,  N.  S.  vol.  vii.  p.  04. 
s  Lectures  on  Surgery.     London,  1808. 


94  INFLAMMATION. 

ments  on  mice,  the  slightest  incision  by  a  scalpel  charged  with  putrid  matter 
was  followed  by  infection,  just  as  in  the  operation  of  vaccination.  Any 
recent  wound,  therefore,  which  has  not  become  covered  by  granulations,  pre- 
sents an  absorbing  surface  through  which  poisons  enter  as  instantaneously  as 
after  a  subcutaneous  injection.  The  internal  surface  of  the  uterus,  after 
throwing  off  its  contents,  possesses  the  same  quality  as  to  capacity  for 
absorption  as  a  recent  wound. 

With  regard  to  the  absorbing  power  of  a  granulating  surface,  less  clear 
opinions  are  held.  Billroth  dressed  granulating  wounds  in  dogs  with  putrid 
matter,  and  reports  that  after  prolonged  contact  no  infection  followed.  He 
infers,  therefore,  that  granulations  when  perfectly  healthy  do  not  absorb.  This 
conclusion,  however,  is  contrary  to  what  analogy  would  lead  us  to  expect 
from  surfaces  consisting  of  living  protoplasm  capable  of  absorbing,  and 
capillary  vessels  so  accessible  as  to  bleed  at  the  slightest  touch.  It  is  matter 
of  demonstration  that  a  poultice  of  garlic  applied  to  a  granulating  ulcer  will 
affect  the  breath ;  and  that  dressings  containing  morphine,  or  stramonium, 
produce  the  specific  effect  of  those  drugs.  This  result  is  undoubtedly  less 
certain  than  absorption  through  a  recent  raw  surface,  as  of  an  incision;  and 
the  difference  is  mainly  to  be  accounted  for  by  the  presence  of  the  outward 
current  of  pus  continually  flowing  from  a  surface  of  granulations,  which  tends 
to  wash  away  foreign  matters  applied  to  it.  But  it  would  not  be  safe  to 
rely  implicitly  upon  the  protective  power  of  a  granulating  surface,  even  when 
perfectly  healthy,  although  it  possesses  a  certain  degree  of  efficiency.  All 
are  agreed,  however,  that  when  granulations  are  unhealthy,  or  when  the 
surface  has  been  destroyed,  even  to  a  limited  degree,  their  protective  power 
against  poisonous  infection  by  absorption  is  not  to  be  trusted.  The  barrier 
of  granulations  set  up  by  the  constructive  inflammatory  effort  to  limit 
advancing  suppuration,  or  gangrene,  has  its  true  explanation  in  the  fact  that 
the  noxious  influence  which  is  causing  a  spreading  suppuration,  or  gangrene, 
has  diminished  in  power,  and  is  no  longer  able  to  keep  up  the  destructive 
process.  It  is  not  correct  to  assume  that  the  primary  purpose  of  such  a  con- 
structive barrier  is,  as  it  may  at  first  glance  seem  to  be,  simply  to  resist  the 
progressive  absorption  and  injurious  effects  of  a  poison. 

Very  many  poisonous  substances  gain  access  to  the  blood  through  the 
lungs,  with  their  enormous  absorbing  surfaces  designed — as  regards  gases 
and  vapors — especially  for  this  purpose.  Carbonic  oxide  gas  reaches  the 
blood,  and  exerts  its  detrimental  influence  upon  its  red  globules,  as  readil}-  as 
the  oxygen  that  vivifies  them,  and,  to  estimate  correctly  the  promptness  with 
which  this  process  of  absorption  takes  place  through  the  lungs,  we  have  only 
to  recall  the  phenomenon,  witnessed  daily,  of  the  production  of  anaesthesia 
by  inhalation  of  the  vapor  of  ether  or  chloroform.  How  far  does  this  power 
of  absorbing  by  the  lungs  include  solid  pulverulent  and  soluble  substances  ? 
Hap] lily  it  is  limited  to  the  transmission  of  the  gases  and  vapors  which  can 
gain  entrance  through  the  glottis,  and  as  to  all  other  materials  is  exceptional. 
That  it  is  within  the  range  of  possibility,  is  proved  by  the  presence  of  finely 
pulverized  carbon  in  the  connective  tissue  outside  of  the  air-tubes  and  in  the 
bronchial  glands,  which  must  have  traversed  the  lining  membrane  of  the 
respiratory  passages.  But  nature  has  furnished  this  membrane-  with  a 
vibratile  ciliated  epithelium,  with  the  especial  design  apparently  of  extrud- 
ing solid  materials  from  the  air-passages,  and  of  preventing  them  from  reach- 
ing the  air-cells. 

The  elder  Mitchell  does  not  dispute  the  belief  that  the  impalpable  crypto- 
genic germs  to  which  he  attributes  contagious  and  epidemic  fevers,  get  into 
the  blood  along  with  the  air  we  breathe;  and  this  question  is  also  applicable 
to  the  germs  which  give  rise  to  infective  surgical  diseases.     This  general  be- 


SYMPTOMS    OF    INFLAMMATION.  95 

lief  has  not  been  seriously  denied,  nor  even  very  carefully  examined.  It  is 
probably,  in  the  main,  destitute  of  any  serious  foundation  in  fact.  Apart 
from  the  argument  derived  from  [Nature's  evident  intention  to  protect  the 
organism  from  the  invasion  of  noxious  agents,  generally,  and  to  prevent  the 
passage  of  solid  substances  through  the  bronchial  passages  to  the  ultimate 
air  cells  of  the  lungs,  especially,  there  are  other  considerations  opposed  to  the 
belief  that  our  bodies  are  so  greatly  exposed  to  harm  through  this  avenue. 

As  regards  noxious  micro-organisms,  Pasteur  asserts  that  one  of  them,  the 
Vibrio  septica,  cannot  develop  when  exposed  to  free  oxygen,  and  infers  the  ex- 
istence of  the  same  peculiarity  in  other  members  of  the  family,  describing 
them  by  the  name— significant  of  this  peculiarity  of  non-viability  when 
exposed  to  oxygen — of  anaerobies.  Here,  at  once,  is  a  valid  source  of  j)ro- 
tection  against  their  noxious  influence  as  introduced  by  the  lungs.  The  ova 
of  the  echinococci  gain  access  to  our  tissues  through  the  digestive  passages, 
and,  undoubtedly,  penetrate  and  traverse  their  walls,  effecting  their  ultimate 
lodgment,  by  preference,  in  the  liver.  "We  can  hardly  assert  that  the  more 
minute  and  indestructible  bacteric  germs — the  dauersporen — might  not  reach 
the  blood  through  the  air  passages.  It  has  been  held,  and  with  probability, 
that  the  malarial  poison  becomes  entangled  in  the  saliva  and  introduced  into 
the  blood  with  the  food ;  and  the  same  avenue  of  entrance  is  of  course  avail- 
able for  bacteria  and  their  germs.  Here  the  well  known  power  of  the  diges- 
tive secretions  comes  in  play  as  a  protective  influence  ;  but  if  they  are  impotent 
as  to  the  ova  of  the  taenia  echinococci  and  the  trichina,  surely  the  same  immu- 
nity may  be  assumed  for  the  indestructible  bacteric  dauersporen.  Possibly 
the  germs  of  other  noxious  microscopic  fungi  may  not  be  so  tenacious  of  life 
as  those  of  the  vibrio  septica,  but  it  is  evident  that  we  must  await  a  more 
extended  knowledge  of  their  nature  and  habits  in  order  to  pursue  this  sub- 
ject intelligently. 

The  facts,  however,  which  tell  most  strongly  against  the  probability  of  the 
habitual  introduction  of  infective  poisons  through  the  lungs,  unless,  indeed, 
they  may  exist  in  the  form  of  gas,  or  vapor,  are  derived  from  clinical  expe- 
rience. When  a  case  of  infective  disease,  erysipelas,  for  example,  is  intro- 
duced into  a  surgical  ward,  as  a  rule,  the  patients  with  open  wounds,  alone, 
receive  the  infection.  Alphonse  Guerin  states  concerning  his  wound  dressing 
of  cotton-wool,  so  largely  tried  at  the  Hotel  Dieu  of  Paris,  that  patients 
whose  wounds  were  thus  protected  escaped  pyaemia,  whilst  their  unprotected 
neighbors  breathing  the  same  air,  almost  invariably  became  victims  of  this 
disease.  ISTussbaum  gives  evidence  that  pyaemia  and  hospital  gangrene  have 
disa} ipeared  from  his  surgical  wards  since  he  adopted  the  practice  of  protecting 
all  wounds  antiseptic-ally.  Trelat  states,  before  the  Surgical  Society  of  Paris, 
that  since  the  advocates  of  Listerism  have  introduced  their  manifold  antisep- 
tic precautions  into  the  hospital  wards,  pyaemia  is  no  longer  to  be  encountered 
there.  Lister  himself  says  freely  that  he  cares  but  little  how  foul  the  air  of  a 
hospital  ward  may  be,  as  regards  its  power  of  inducing  infectious  diseases, 
provided  that  antiseptics  are  thoroughly  employed  in  dressing  the  patients' 
wounds.  Now,  if  the  infective  poison  of  pyaemia  habitually  reached  the 
blood  through  the  lungs,  protective  means  applied  to  open  wounds,  whilst  the 
patient  was  constantly  breathing  the  same  infected  air,  would  not  prove  thus 
effective  in  preventing  it. 


Symptoms  of  Inflammation. 

The  ordinary  symptoms  which  characterize  the  condition  of  inflammation 
are  mainly  included  under  the  cardinal  signs  recorded  by  Celsus :  redness  and 


96  INFLAMMATION. 

heat,  with  swelling  and  pain.     To  these,  modern  pathology  adds  impairment  of 
function  of  the  inflamed  part,  and  the  presence  of  more  or  less  fever. 

The  symptoms  of  inflammation  with  which  daily  experience  renders  us 
familiar,  are  readily  explained  by  the  subjective  phenomena  which  character- 
ize the  process,  as  revealed  by  microscopical  study  of  tissues  in  which  in- 
flammation has  been  artificially  excited  in  the  lower  animals ;  and  by  studying 
the  causes  which  have  been  found,  by  experiments  upon  the  lower  animals, 
competent  to  give  rise  to  the  condition. 

Thus,  Redness,  one  of  the  most  obvious  and  characteristic  signs  of  inflam- 
mation, and  the  symptom,  perhaps,  most  rarely  absent,  is  explained  by  the 
increased  amount  of  blood  flowing  into  the  vessels  of  the  part,  and  for  a  time 
remaining  there.  The  phenomena  of  afflux  of  blood  to  an  inflaming  part, 
and  the  temporary  dilatation  of  the  bloodvessels  by  which  the  increased 
amount  of  blood  is  accommodated  in  them,  are  the  earliest  and  most  striking 
of  the  changes  which  follow  injury,  and  which  constitute  inflammation. 
With  the  explanation  of  the  causes  of  these  phenomena  we  are  not  at  present 
concerned,  beyond  a  recognition  of  the  following  facts.  Redness  may  arise 
from  }mssive  hyper&mia,  or  congestion  following  any  cause  which  impedes  local 
circulation,  whether  the  cause  be  a  simple  mechanical  obstruction,  or  a  func- 
tional failure,  on  the  part  of  the  vessels,  as  a  consequence  of  an  impaired 
quality  of  blood,  or  of  defective  vaso-motor  nervous  action.  Redness  may 
also  arise  from  active  hypercemia,  as  in  blushing,  or  in  the  flushing  of  the  face 
which  has  a  reflex  gastric  origin,  or  as  provoked  by  any  of  the  more  common 
exciting  causes  of  inflammation,  which  have  proved  incompetent  to  produce 
the  condition  beyond  causing  an  afflux  which  has  ceased  at  the  stage  of  active 
hyperemia.  In  neither  of  these  cases  is  the  redness  regarded  as  a  symptom 
of  inflammation.  The  line  of  distinction  between  persistent  active  hyper- 
emia and  inflammation,  is  usually  considered  to  be  marked  by  the  occurrence 
of  exudation.  Nevertheless  we  should  deceive  ourselves  if  this  view  were 
regarded  as  final.  There  is  a  certain  degree  of  identity  between  hyperemia, 
or  congestion,  and  inflammation ;  and  the  reason  why  the  redness  produced  at 
will  by  roughly  applying  friction  to  the  conjunctiva,  or  to  the  skin,  disappears 
shortly,  instead  of  going  on  to  exudation  and  cell  germination,  is  not  entirely 
clear.  After  hyperemia  of  long  duration,  serous  exudation  does  take  place, 
not  rarely,  and  previous  to  its  occurrence  there  is  increase  of  bulk,  and  also 
of  heat,  in  the  congested  part.  After  death,  capillaries  which  have  been  thus 
subjected  to  distension  are  found  to  present  fusiform  or  ampullar  dilatations.1 

Phenomena  attributed  to  hyperemia  occur  in  a  lower  extremity  after  a  suc- 
cessful ligature  of  the  femoral  artery.  The  collateral  circulation,  even  when 
ample,  is  at  first  retarded  by  cutting  off  the  arterial  vis  a  tergo,  and  although 
for  a  day  or  so  the  heat  of  the  limb  is  distinctly  greater  than  that  of  the 
sound  one,  this  difficulty  is  shortly  adjusted,  and  the  occurrence  of  inflam- 
mation from  this  cause  is  almost  unknown.  The  redness,  from  capillary 
distension,  that  follows  pressure  of  any  duration  which  has  been  suddenly  re- 
moved, is  usually  called  hypersemia,  which,  in  this  form,  causes  overgrowth  of 
the  epidermis,  and  explains  the  production  of  corns  on  the  feet.  The  com- 
plete removal  of  the  contents  of  a  habitually  distended  bladder  is  in  most 
instances  followed  by  passive  congestion,  which  terminates  in  patches  of 
ulceration  and  gangrene  of  the  vesical  mucous  membrane.  The  systematic 
use  of  a  local  li<>t  air  bath  to  stimulate  the  growth  of  a  wasted  limb,  in  a 
child,  has  resulted  in  the  production  of  a  distinctly  stronger  growth  of  hair 
upon  it,  evidently  the  result  of  the  surface  hypersemia  provoked  by  the  heat. 

1  Comil  and  Kanvier. 


SYMPTOMS    OF   INFLAMMATION.  97 

It  would  seem,  therefore,  even  from  these  few  facts,  that  the  condition  of  hy- 
peremia has  both  a  constructive  and  a  destructive  aspect,  determined  by  the 
circumstances  which  give  rise  to  it. 

Redness  is  usually  light  in  tint,  at  first,  and  it  becomes  deeper  as  the  in- 
flammation increases  in  intensity.  When  a  poison  is  present  in  the  blood,  the 
redness  may  assume  a  livid  tint,  as  in  certain  grave  phases  of  the  eruptive 
fevers.  The  eruptions  of  syphilis  are,  for  the  most  part,  copper  colored ; 
after  a  snake-bite  the  redness  is  usually  mottled.  When  the  over-distended 
capillaries  of  an  inflamed  surface  rupture,  the  redness  shows  darker  points  of 
extravasation.  The  blood  may  be  removed  from  an  over-distended  vascular 
network  by  temporary  pressure,  as  in  the  earlier  stages  of  a  conjunctivitis, 
and  the  redness,  for  the  moment,  entirely  removed,  the  white  sclerotica  show- 
ing through.  Its  dependence  upon  the  presence  of  blood  in  gorged  blood- 
vessels is  thus  demonstrated.  The  term  arborization  is  applied  to  a  vascular 
area  or  network  of  vessels,  thus  distended  with  blood,  when  the  outline  of 
the  vessels  is  still  distinguishable.  When  redness  presents  itself  as  an  uniform 
sheet,  as  in  scarlatina,  or  erysipelas,  it  is  not  easily  distinguished  from  stain- 
ing by  extravasation  or  by  transudation  of  blood-colored  serum  through  the 
capillary  walls,  especially  when  the  redness  cannot  be  made  to  disappear  by 
temporary  pressure.  In  the  beginning  of  inflammation  in  the  non- vascular 
tissues,  such  as  the  cornea  and  cartilage,  redness  is  not  recognizable. 

The  increased  Heat  of  an  inflamed  part  is  to  be  ascribed  to  the  greater 
amount  of  red  blood  present  in  the  part,  and  to  the  greater  activity  of  the 
vital  processes,  normal  and  abnormal,  which  are  taking  place  in  it  and  evolv- 
ing a  corresponding  increase  of  the  local  temperature.  When  fever  is  present, 
the  higher  temperature  of  the  blood  aids  in  increasing  the  local  heat. 

The  presence  of  increased  heat  in  an  inflamed  part,  when  not  too  far  re- 
moved from  the  surface,  is  usually  recognizable  by  the  patient,  but  not  so 
readily  and  certainly  as  by  the  hand  of  another  person.  It  is  verified  by 
comparison  with  the  temperature  of  another  part  of  the  body.  Thus,  in  a 
knee-joint,  when  inflammation  is  suspected,  its  surface  temperature  is  com- 
pared with  that  of  the  opposite  knee.  It  has  been  proved  by  experiment1 
that  this  increase  of  local  heat  is  mainly  the  result  of  the  local  causes  already 
mentioned  ;  it  has  rarely  been  found  to  exceed,  and  in  most  cases  it  has  not 
reached,  the  temperature  of  the  blood.  Since  the  very  general  clinical  use 
of  the  thermometer  this  fact  has  been  amply  verified.  Ingenious  instruments 
have  also  been  employed  for  accurately  measuring  local  temperature.  There 
is  reason  to  believe  that  the  temperature  of  inflamed  parts  is  not  so  readily 
lowered  by  evaporating  lotions,  or  the  application  of  ice,  as  that  of  correspond- 
ing sound  parts. 

The  Swelling  in  inflammation  is  due  in  part  to  the  greater  quantity  of 
blood  present  in  the  dilated  vessels,  and  in  part  to  the  materials,  liquid  and 
solid,  which  exude  through  their  walls,  as  well  as  to  extravasation  from 
rupture,  which  often  occurs  in  consequence  of  the  force  attending  the  afflux 
of  blood  to  the  inflammatory  focus.  It  is  also  due  in  part  to  cell  germination 
and  to  the  formation  of  new  capillary  vessels,  which,  as  the  injured  tissues 
revert  to  their  embryonic  state  under  the  incitement  to  constructive  inflam- 
mation, contribute  materially  to  their  increase  of  bulk.  The  occurrence  of 
swelling  in  a  part,  without  other  signs,  is  not  very  significant  of  inflammation, 
for  it  is  liable  to  occur  frequently  from  other  causes.  ISTor  is  it  always  [ire- 
sent  in  inflammation,  especially  at  first,  as,  for  example,  in  simple  osteitis, 

1  John  Hunter  ;  Andral  and  Gavarret ;  Marey. 
VOL.  I. — 7 


98  INFLAMMATION. 

and  in  inflammations  of  serous  and  mucous  membranes,  before  exudation  lias 
taken  place  into  the  connective  tissue  underlying  these  membranes.  In  fact, 
the  looseness  of  texture  and  distensibility  of  the  connective  tissue  of  an  in- 
flamed part  is  a  condition  necessary  for  the  production  of  this  symptom  in 
any  considerable  degree. 

The  Pain  so  rarely  absent  in  inflammation  is  explained  by  the  local  irrita- 
tion of  the  nerves  of  a  part  by  the  causes  which  have  excited  the  condition, 
as  by  the  contact  of  a  splinter,  or  an  acrid  poison,  or  by  a  burn,  and  also  by 
the  tension  and  partial  laceration  of  nervous  filaments  by  any  of  the  causes 
which  beget  swelling.  The  sudden  darting  pains  which  are  felt  in  an  abscess 
approaching  maturity,  mark  the  rupture  of  small  nerves  stretched  beyond 
their  capacity  of  resistance  by  the  growing  bulk  of  the  collection  of  pus. 
Pain  alone  is  often  a  valuable  sign  of  a  deep-seated  local  inflammation,  where 
its  distance  from  the  surface  of  the  body  has  prevented  the  recognition  of 
heat,  redness,  or  swelling.  The  first  symptom  of  a  subfascial  abscess  of  the 
iliac  fossa  is  pain  in  extending  the  thigh.  The  knotted  hardness  and  keen 
sensitiveness  over  the  track  of  the  lymphatic  trunks  precedes  the  redness  in 
lymphangeitis.  The  extreme  tenderness  to  the  touch  of  the  lymphatic  gland 
in  front  of  the  ear,  is  one  of  the  characteristic  prodromata  by  which  we  are 
able  to  foretell  an  outbreak  of  erysipelas  of  the  face.  The  exemisite  sensi- 
bility on  pressure  over  the  vein,  is  the  earliest  diagnostic  symptom  of  a 
phlebitis. 

Pain  varies  much  in  character  according  to  the  nature  and  ordinary  sensi- 
bility of  the  parts  affected.  When  they  are  unyielding,  as  in  periostitis  in 
the  socket  of  a  tooth  threatening  abscess,  or  in  whitlow — which  involves  the 
dense  fibrous  structures  surrounding  the  bone  at  the  end  of  a  finger — or  in  a 
crisis  of  gout,  the  pain  amounts  to  torture.  In  inflammation  of  the  substance 
of  the  testis,  enveloped  by  the  unyielding  tunica  albuginea,  or  of  the  tissues 
within  the  globe  of  the  eye,  or  in  the  external  meatus  of  the  ear,  or  in  the 
interior  of  bone,  pain  is  notoriously  severe.  Pain  of  a  pulsatile  or  throbbing 
character  is  caused  by  the  increased  force  of  the  smaller  arteries  bring- 
ing blood  to  the  focus  of  inflammation,  and  by  the  obstruction  to  free 
circulation  caused  by  the  swelling,  and  possibly  increased  by  stasis,  at 
the  centre  of  the  inflamed  area.  The  condition  of  strangulation,  in  which 
the  pain  is  excessive,  takes  place  when  the  veins  of  an  inflamed  part  are 
obstructed  by  the  pressure  of  the  swelling,  so  that  the  blood  cannot  escape 
through  them  whilst  it  is  still  being  brought  by  the  arteries.  This  is  liable 
to  occur  in  epididymitis  and  acute  orchitis,  in  which  the  turgid  vessels  of 
the  spermat  ic  cord  are  encircled  by  the  unyielding  borders  of  the  external 
abdominal  ring.  On  the  other  hand,  pain  is  not  rarely  trivial,  or  even  entirely 
absent',  in  grave  inflammations  where  the  parts  affected  are  of  soft  consistence 
and  have  free  room  to  swell,  as,  for  example,  in  pneumonia, 

Pain  presents  variety  in  quality  as  well  as  in  degree,  and  expressions  are 
in  common  use  for  indicating  certain  of  its  varieties.  Thus  where  a  nerve 
of  any  size  is  subjected  to  pressure,  as  from  a  collection  of  pus,  the  pain  is 
aching,  sometimes  tingling,  ;is  when  the  ulnar  nerve  where  it  lies  behind  the 
internal  condyle  of  the  humerus  has  been  bruised.  In  many  skin  inflamma- 
tions pain  takes  the  form  of  itching;  in  others,  again,  this  form  of  pain  is 
entirely  absent,  as  in  the  eruptions  of  syphilis.  An  abscess  forming  in  the 
head  of  the  tibia  causes  a  boring  pain,  which  is  distinctly  worse  at  night. 
An  abscess  forming  slowly  in  soft  parts  produces  a  sen.se  of  weight,  or  a  tensive 
pain  ;  when  about  to  point  it  gives  rise  to  lancinating  pain.  The  pain  of  an 
erysipelas  is  described  as  burning  or  sore.  Thus  the  pain  of  inflammation  has 
a  language  of  its  own,  a   familiarity  with  which  is  useful  in  diagnosis,  espe- 


TRAUMATIC    OR   INFLAMMATORY   FEVER.  99 

cially  in  determining  the  seat  of  an  abscess.  As  pain  is  a  common  symptom 
in  other  and  non-inflammatory  affections,  its  value  as  a  symptom  of  inflam- 
mation is  to  be  determined  in  many  cases  by  the  coexistence  of  other  corrob- 
orative signs. 

Impairment,  or  more  or  less  Entire  Abolition  of  Function,  is  almost 
always  present  when  a  part,  or  an  organ,  is  the  seat  of  serious  inflammation. 
The  function  of  the  eye  is  suspended  in  iritis ;  in  mumps  there  is  dryness  of 
the  mouth  on  the  side  of  the  parotid  gland  affected,  from  arrest  of  its  secre- 
tion ;  the  voice  is  lost  or  impaired  when  the  chordce  vocales  are  involved  in 
the  local  inflammation  in  a  laryngeal  catarrh ;  muscle  contracts  with  difficulty 
when  inflamed,  and  its  contraction  is  accompanied  by  peculiar  and  severe 
pain.  The  "  stitch  in  the  side"  of  a  pleurisy  impedes  respiration,  and  the  ex- 
udation in  pneumonia,  if  sufficiently  extensive,  extinguishes  this  function.  In 
peritonitis,  the  diaphragm  contracts  imperfectly,  and  the  respiratory  move- 
ments are  limited  to  the  thorax.  In  short,  in  every  severe  local  inflammation 
there  is  a  certain  degree  of  interference  with  function  throughout  the  whole 
economy,  and  this  is  especially  marked  in  connection  with  the  condition  of 
fever,  which,  under  such  circumstances,  is  rarely  absent. 

Locally,  the  conditions  of  textured  life  are  altered  in  a  greater  or  less  degree 
by  their  participation  in  the  changes  which  constitute  inflammation.  These 
changes  involve,  as  we  have  seen,  the  conditions  of  local  blood  supply,  and 
therefore  nutrition  is  disturbed  as  wTell  as  innervation.  They  include  at  first 
increase  of  local  heat,  and  arrest  of  glandular  and  follicular  secretion,  the  re- 
sult, apparently,  of  the  intense  active  hyperemia,  causing  dryness.  In  certain 
phases  these  earlier  changes  are  well  shown  in  simple  cutaneous  erysipelas. 
After  this  disease  has  run  its  course  in  the  scalp,  the  epidermis  exfoliates, 
and  the  hair  falls,  showing  that  the  function  of  the  hair  bulbs  has  been  sus- 
pended. It  is  to  be  noticed,  however,  as  illustrating  the  characteristic  quality 
of  the  inflammatory  condition — the  absence  of  an  intrinsic  destructive  ten- 
dency— that  old  surface-ulcers,  which  have  been  lingering  in  an  indolent  con- 
dition and  resisting  means  of  cure,  often  get  well  promptly  after  an  attack  of 
erysipelas  involving  the  integument  around  them.     The  explanation  of  this 


a  purely  reparative  effort  in  the  tissues  involved  in  the  pre-existing  lesion. 
The  ultimate  tendency  in  all  tissues  when  involved  in  inflammation  is,  as  we 
know,  to  revert  to  the  embryonic  condition,  as  a  preliminary  stage  to  recon- 
struction; and  the  parts  involved  in  an  indolent  or  languidly  granulating 
ulcer,  having  already  attained  this  stage,  in  a  degree,  are  appropriately  stimu- 
lated, by  the  incidentally  increased  blood  supply  accompanying  an  invasion 
ot  cutaneous  erysipelas,  to  take  on  a  new  and  successful  effort  at  recon- 
struction. 

Short  of  complete  reversion  to  the  embryonic  condition,  that  is,  the  state  of 
"  indifferent"  or  "  granulation"  tissue,  there  are  endless  phases  of  local  textural 
change  resulting  from  inflammation  which  are  daily  recognizable  by  the 
clinical  eye.  These  changes  affect  inflamed  parts  variously,  as  regards  their 
bulk,  their  consistence,  and  their  general  aspect  and  quality. 

Traumatic  or  Inflammatory  Fever. 

As  a  symptom  of  inflammation,  fever,  in  some  degree,  is  rarely  absent 
after  a  wound  or  injury  of  any  gravity;  and  its  more  common  form  is  known 


100  INFLAMMATION. 

as  "traumatic"  or  "simple  inflammatory"  fever.  It  is  more  likely  to  be 
slight  in  its  manifestations,  or  even  to  be  entirely  absent,  after  simple  and 
uncomplicated  injuries,  such,  for  example,  as  an  incised  wound  which  is 
uniting  promptly  by  the  first  intention.  After  a  contused  wound  or  a  partial 
crushing,  traumatic  fever  would  be  more  certain  to  occur  and  to  be  well 
marked,  and  to  merge,  possibly,  into  a  graver  form  of  surgical  fever. 

As  a  rule,  fever  makes  its  first  appearance  in  the  evening  of  the  day  on 
which  a  serious  injury,  say  a  compound  fracture,  has  been  received,  following 
the  reaction  from  the  collapse  or  shock  of  injury  which  takes  place  more  or 
less  slowly  according  to  the  gravity  of  the  case.  If  a  wound  involve  per- 
fectly healthy  tissues,  and  has  been  promptly  and  properly  cared  for,  or  if  it 
be  a  subcutaneous  lesion,  such  as  a  simple  fracture,  febrile  symptoms  may 
not  show  themselves  for  twenty-four  hours,  or  even  a  longer  time,  or  they 
may,  possibly,  not  appear  at  all. 

In  a  healthy  young  man  whose  hand  was  utterly  crushed  between  cog-wheels,  re- 
quiring primary  amputation,  fever  did  not  manifest  itself  for  thirty-six  hours,  and  was 
then  limited  by  a  temperature  of  100°  Fahr.,  the  wound  uniting  by  the  first  intention 
except  where  the  ligatures  of  silk  prevented ;  and  before  the  sixth  day  the  symptoms 
had  disappeared. 

In  an  amputation  at  mid-leg  for  a  crushed  foot,  through  parts  not  entirely  sound, 
fever  showed  itself  the  same  evening,  and  continued  until  the  beginning  of  the  second 
week. 

In  a  similar  case,  in  which  the  operation,  through  reluctance  to  submit  to  mutilation, 
was  delayed,  fever  came  on  within  a  few  hours  ;  by  the  end  of  the  week  it  had  assumed 
a  septicemic  character,  and  before  the  end  of  the  second  week  it  had  terminated  fatally, 
the  temperature  having  risen  to  104°+  Fahr.,  the  blood,  after  death,  coagulating 
imperfectly. 

This  case  affords  an  example  of  an  unfavorable  termination  of  what  seemed 
to  be  at  first  simple  traumatic  or  inflammatory  fever,  and  it  illustrates  the 
mode  in  which  traumatic  fever  reaches  this  exceptional  termination,  as 
observed  clinically,  in  fatal  cases,  namely,  by  merging  into  another  form  of 
surgical  fever  attended  by  greater  danger  to  life.  This  difference  in  the 
character  of  the  accompanying  fever  marks  also  the  distinction  which  is 
assumed  to  exist,  in  the  language  of  the  day,  between  a  health}-  or  construc- 
tive inflammatory  process  and  an  unhealthy  or  "  infective"  inflammation. 

As  a  rule,  traumatic  fever  is  moderate  in  character,  and  terminates  early  and 
spontaneously.  In  connection  with  subcutaneous  wounds  and  injuries,  as  in 
a  case  of  simple  fracture,  it  is  either  entirely  absent  or  very  mild  and  tran- 
sient ;  and  the  same  is  true,  for  the  most  part,  of  wounds  which  have  been 
thoroughly  protected  by  antiseptic  dressings,  and  in  which  catgut  ligatures 
have  been  employed. 

The  aspect  of  a  patient  on  the  invasion  of  traumatic  fever  becomes  slightly 
altered  ;  his  countenance  is  somewhat  pinched  and  anxious ;  he  is  a  little 
restless,  apt  to  resent  disturbance,  and  awakes  frequently  from  his  sleep,  lie 
is  conscious  of  feeling  fatigued,  hot,  and  thirsty,  and  has  usually  a  dry  mouth. 
The  tongue  gradually  becomes  coated,  and  there  is  little  or  no  desire  for  food. 
Tlir  urine  is  scanty  and  deeper  in  color.  The  pulse  is  more  frequent  than  it 
should  be,  and  the  thermometer,  under  the  tongue,  shows  a  decided  increase 
of  temperature.  Although  the  patient  may  feel  slightly  chilly  on  exposure, 
simple  traumatic  fever  is  not  usually  ushered  in  by  a  rigor,  and  the  tempera- 
ture rarely  exoeteds  102.5°  Fahr.  The  fever  reaches  its  climax  in  about  thirty- 
six  hours;  it  may  continue,  with  a  slight  remission  in  the  morning  and  a 
corresponding  increase  towards  evening,  for  two,  three,  or  four  days.  About 
this  time  the  fever  begins  to  decline,  the  temperature  diminishing,  and  the 
pujse  -i-adually. returning  to  the  natural  standard;  so  that,  at  the  end  of  a 


TRAUMATIC    OR    INFLAMMATORY    FEVER.  101 

week,  the  febrile  movement  has  ceased.  Not  infrequently,  when  suppuration 
takes  place  in  a  wound  at  the  usual  period,  say  from  the  third  to  the  fifth 
day,  the  traumatic  fever  declines  coincidently  with  the  appearance  of  pus 
and  the  diminution  of  the  local  swelling  and  tension. 

This  is  the  typical  course  of  traumatic  or  inflammatory  fever.  If  it  does  not 
disappear  promptly  within  this  limit  of  time,  there  is  reason  to  suspect  deeper 
suppuration,  or  some  other  complication  of  the  local  inflammation,  to  account 
for  the  continuance  of  the  febrile  symptoms,  which  can  no  longer  be  ascribed 
to  simple  traumatic  fever,  but  threaten  to  assume  the  character  of  septicaemia, 
pyaemia,  or  hectic.  These  phases  of  febrile  action  will  be  considered  here- 
after ;  at  present  we  shall  confine  our  remarks  to  the  simpler  affection. 

The  personal  quality  of  the  patient  as  to  constitution,  condition  of  health, 
and  surroundings,  besides  the  extent  and  locality  of  the  injury,  have  their 
influence  in  producing  the  various  phases  of  traumatic  fever  encountered  by 
the  surgeon,  and  in  determining  their  gravity ;  but  this  influence,  like  the 
cause  and  nature  of  the  fever  itself,  is  both  complex  and  obscure.  When  an 
inflammation  is  rapid  in  its  development,  characterized  by  strongly  marked 
symptoms,  and  attended  by  much  local  excitement,  it  is  said  to  be  acute,  and, 
under  these  circumstances,  the  symptoms  of  the  accompanying  traumatic 
fever  are  well  marked  and  more  intense.  The  term  sthenic  is  used  to  designate 
fever  of  this  type ;  its  occurrence  is  not  incompatible  with  a  previous  high 
grade  of  sound  health.  Its  acme  or  fastigium  is  rapidly  attained,  and  its 
defervescence  or  lysis  is  usually  prompt  and  complete.  On  the  other  hand, 
in  an  organism  which  has  been  previously  the  seat  of  chronic  disease,  a  new 
injury  is  not  likely  to  be  resented  by  a  high  grade  either  of  inflammation  or 
of  traumatic  fever. 

A  boy,  aged  17,  was  subjected,  at  the  New  York  Hospital,  to  amputation  of  the 
thigh  at  its  lower  third  for  "  chronic  synovitis"  of  the  knee-joint.  The  next  day  his 
habitual  aspect  of  depression  had  distinctly  improved ;  his  tongue  was  noticeably  less 
red ;  his  pulse  was  less  frequent  than  the  day  before  the  operation ;  he  had  slept  more 
continuously  during  the  night — apparently  in  consequence  of  entire  relief  from  the 
aching  joint  pain.  In  this  case  no  febrile  movement  occurred  until  the  evening  of  the 
third  day,  when  there  was  slight  heat  and  tension  of  the  stump  and  a  moderate  rise  of 
temperature.  On  the  next  day  there  was  a  flow  of  pus  along  the  track  of  the  ligatures, 
the  tension  of  the  stump  had  subsided,  the  general  temperature  had  fallen,  and  all  evi- 
dence of  traumatic  fever  had  disappeared.  Subsequent  recovery  was  unusually  rapid 
and  complete.  Except  where  the  presence  of  the  ligatures  had  provoked  suppuration, 
the  inflammation  following  the  amputation  was  limited  entirely  to  its  constructive 
phase. 

Primary  amputation  of  the  thigh  rendered  necessary  by  injury  is  rarely 
followed  by  a  result  so  innocent,  as  regards  inflammatory  or  febrile  reaction, 
as  in  this  amputation  for  disease.  Even  in  health,  the  suddenness  of  an 
injury  favors  subsequent  febrile  reaction.  Within  certain  limits,  previous 
training  by  illness  and  pain  renders  the  organism  more  tolerant.  The  signifi- 
cance of  these  facts  is  embodied  in  the  surgical  doctrine  that  secondary  ampu- 
tations for  disease  involve  less  danger  than  primary  amputations  for  injury. 
They  are  introduced  here  as  illustrative  of  traumatic  fever  from  a  clinical 
point  of  view,  awaiting  a  solution,  from  physiology,  of  the  difficult  problem 
ol  the  nature  and  immediate  cause  of  fever,  by  which  they  are  to  be  ulti- 
mately explained. 

^  hat  actually  constitutes  the  condition  to  which  we  give  the  name  ot 
fever,  may  be  stated,  in  plain  terms,  without  speculation.  ^  Clinical  observa- 
tion, aided  by  research  and  experiments  on  the  lower  animals,  has  led  to  cer- 
tain conclusions  which  are  admitted  by  all.  The  essential  feature  of  fever  is 
an  increase  in  the  temperature  of  the  blood;  and  this  increase  may  reach 


102  INFLAMMATION. 

eight,  or  even,  in  extreme  cases,  ten  degrees  Fahrenheit.  With  the  certain 
knowledge  that  the  organism  possesses  a  self-regulating  power  as  regards  its 
temperature,  which,  under  all  the  varying  circumstances  of  climate,  preserves 
the  blood  at  or  about  the  same  degree  of  heat — 99°  Fahr. ;  when,  shortly 
after  the  infliction  upon  the  body  of  a  physical  injury,  this  temperature  is 
observed  to  rise,  as  indicated  by  an  instrument  of  precision,  a  certain  number 
of  degrees,  and  to  retain  its  abnormal  elevation  for  some  hours,  this  phenom- 
enon, alone,  justifies  the  observer  in  the  conclusion  that  fever  is  present.  All 
the  other  features  of  the  state  of  fever  arrange  themselves  around  this  central 
phenomenon,  which  is  pathognomonic.  The  injured  person  may  not  be  con- 
scious of  this  increase  of  heat.  He  may,  in  fact,  and  generally  does,  at  first, 
feel  distinctly  chilly.  What  is  technically  called  a  chill,  or  rigor,  that  so 
commonly  occurs  at  the  onset  of  fever,  coincides  with  a  rise,  more  or  less 
sudden  and  rapid,  in  the  temperature,  as  indicated  by  a  thermometer  placed 
beneath  the  tongue  of  the  patient.  He  may  be  shivering  with  cold,  and  yet 
the  thermometer  may  indicate  a  rise  of  three  or  four  degrees.  This  shows 
that  the  subjective  sensations  of  the  patient  cannot  be  trusted.  His  skin  may 
be  biting  hot  to  the  hand  of  the  surgeon,  and  yet  he  may  be  shivering.  At 
a  later  period  he  becomes  unpleasantly  conscious  of  the  increased  heat  of  his 
body ;  but  even  now  chilly  sensations  may  alternate  with  the  consciousness 
of  intense  heat. 

These  phenomena  accompany  the  invasion  of  most  of  the  graver  forms  of 
surgical  fever.  Indeed  there  is  a  certain  significance  of  gravity  always  con- 
ve}7ed  by  the  occurrence  of  a  chill  in  a  surgical  case ;  and  the  intensity  and 
duration  of  a  chill  is  properly  regarded  as  an  indication  of  the  degree  of  dan- 
ger present.  But,  as  a  rule,  in  the  milder  forms  of  traumatic  fever  the  chill 
is  slight,  and  often  entirely  absent. 

Coincidently  with  the  increased  temperature  of  the  blood  in  fever,  there  are 
other  evidences  of  derangement  in  the  heat-producing  machinery  of  the  body, 
besides  the  somewhat  illusory  sensations  of  the  patient  himself.  There  are 
evidences  that  tissues  are  undergoing  premature  destruction  by  combustion, 
which,  in  the  ordinary  balance  of  nutrition,  escape  in  consequence  of  the  daily 
provision  of  an  adequate  supply  of  material  for  keeping  up  heat,  by  food.  In 
fever,  appetite  is  wanting,  digestion  and  assimilation  are  reduced  to  a  mini- 
mum, and  yet  heat  production  is  kept  up  to  the  standard  of  health.  Hence 
the  excretion  of  urea  is  almost  if  not  quite  tripled,  as  a  result  of  the  combus- 
tion of  albuminous  materials,  e.  g. ,  blood  plasma,  blood  corpuscles,  the  sarcous 
element  of  muscular  tissue,  etc.  Hence  the  increase  of  potassium  salts  in  the 
urine,  the  doubled  excretion  of  carbonic  acid,  the  absorption  of  adipose  tissue, 
and  the  consequent  emaciation  which  always  accompanies  fever.  In  the  dogs, 
so  carefully  watched  by  Weber  in  his  valuable  experiments  undertaken  to 
elucidate  the  nature  of  fever,  emaciation  took  place  more  rapidly  in  dogs  with 
fever,  eating  as  much  as  they  could  be  made  to  eat,  than  in  dogs,  under  simi- 
lar circumstances,  but  without  fever,  who  were  deprived  of  all  food.  In  other 
words,  emaciation  took  place  more  rapidly  from  fever,  than  from  inanition. 
Clinical  observation  affords  confirmation  of  this  statement. 

It  is  thus  evident  that  heat  production  in  the  human  body,  during  fever, 
is,  so  to  speak,  an  expensive  process.  Although  the  heat  in  fever  does  not 
transcend  tin-  aggregate  of  health,  it  is  kept  up  by  the  forced  consumption  of 
substances  in  the  body  too  valuable  to  be  consumed  for  the  purposes  of  fuel — 
the  supply  of  heat-producing  food  from  without,  through  the  ordinary  chan- 
nels, being  cut  off.  We  are  forced  to  conclude,  therefore,  that  fever,  like  in- 
flammation, is  essentially  a  disorder  of  nutrition.1    This  position,  based  on  the 

1  The  following  quotation  contains  the  conclusions  as  to  the  nature  of  fever  readied  by  Prof. 
Wood  from  his  recent  experimental  researches,  which  constitute  the  latest  as  well  as  the  best  evi- 


TRAUMATIC    OR    INFLAMMATORY    FEVER.  103 

best  evidence  thus  far  attained,  brings  us  however  but  little  nearer  to  a  know- 
ledge of  its  essential  nature  and  immediate  cause. 

As  throwing  light  upon  the  causes  of  surgical  fever,  it  is  worthy  of  notice 
that,  in  his  elaborate  experiments,  Senator  resorted  to  a  subcutaneous  injection 
of  fresh  healthy  pus  for  the  purpose  of  producing  the  state  of  fever  in  his 
do<:'s  artificially.  He  habitually  employed  this  pyrogenic  device,  and  it  always 
succeeded.  In  two  or  three  hours  after  the  injection  of  the  pus,  the  tempera- 
ture of  the  blood  began  to  rise  until  it  reached  a  certain  figure,  at  or  about 
which  it  remained  for  two  days  or  so,  and  then,  unless  the  injection  was  re- 
peated, it  subsided;  meanwhile  the  animal  manifested  all  the  symptoms  of 
fever.  This  affords  a  demonstration  of  what  has  been  recognized  as  the  fever 
producing,  or  "  infective"  power  of  the  products  of  ordinary  inflammation. 
On  the  basis  of  these  and  similar  experiments,  Dr.  Sanderson1  formulates,  very 
concisely,  the  conclusion  that  "fever  is  the  product  of  a  fever-producing  cause 
contained  in  the  blood  or  tissue  juices,  the  morbific  action  of  which  on  the 
organism  is  antecedent  to  all  functional  disturbances  whatever."  He  also 
employs  the  term  "  infective  agent"  as  synonymous  with  "  fever-producing 
cause"  and  speaks  of  fever  as  "from  first  to  last  a  disorder  of  protoplasm." 
Prof.  Wood,  in  his  conclusions,  expresses  the  following  opinion  concerning 
the  causes  of  fever:  "In  most  cases  of  fever,  and  probably  in  all  cases  of  se- 
rious fever,  there  is  a  definite  poison  circulating  in  the  blood,  the  poison 
sometimes  having  been  formed  in  the  system,  sometimes  having  entered  the 
organism  from  without." 

This  may  be  regarded  as  a  fair  exposition  of  the  doctrine  of  the  day  as  re- 
gards fever.  The  theory  so  long  prevalent  that  fever  took  its  origin  in  dis- 
order of  the  nervous  centres,  has  been  given  up  by  recent  authorities  in  surgical 
pathology.  Billroth  has  rejected  it;  so  also  have  the  French  encyclopedists. 
All  avow  a  belief  in  a  material  cause;  and  the  search  for  this  material  cause, 
which  includes  also  the  cause  of  inflammation,  is,  at  the  present  time  the  fore- 
most problem  of  surgical  patholog}-.  It  has  been  thought  to  exist  in  the 
"  infective  quality  of  the  products  of  inflammation ;"  in  putridity — as  in  the 
soluble  "sepsin"  of  Bergman — the  analogue  of  serpent  venom;  and  finally,  in 
the  micro-organisms  which  have  been  proved  to  be  so  intimately  associated 
with  putrefaction.  There  seems  to  be  no  valid  reason  why  there  should  be  a 
solitary  material,  pyrogenic,  or  phlogogenic  principle.  There  may  be,  and 
judging  from  clinical  experience  there  are,  probably,  multiple  material  causes 
both  of  surg-ical  fever  and  of  inflammation;  and  some  of  them  are,  apparently, 
being  identified. 

It  is  questionable  if  it  be  wise  to  reject  the  influence  of  the  nervous  system 
so  entirely  in  the  search  for  these  material  causes  of  fever.  That  its  influence 
has  been  heretofore  vaguely  exaggerated,  is  proven,  as  one  of  the  direct  results 
of  more  certain  and  accurate  knowledge;  but,  as  in  all  fluctuations  in  human 
opinions,  there  is  danger  that  the  opposite  views  may  be  carried  to  ultraism, 
and  that  belief  may  become  a  matter  of  fashion.  The  writings  of  the  great 
English  masters  of  surgery  in  the  early  part  of  this  century  offered  little  that 
the  mind  could  grasp  in  explanation  of  the  nature  and  causes  of  inflammation 

denoe  mi  the  subject  since  the  lectures  on  calorification  of  Claude  Bernard,  in  1876  :  "  Fever  is  a 
complex  nutritive  disturbance  in  which  there  is  an  excessive  production  of  such  portion  of  the 
>">  lily  heat  as  is  derived  from  chemical  movements  in  the  accumulated  material  of  the  organism, 
tin-  surplus  being  sometimes  more  than  the  loss  of  heat  production  resulting  from  abstinence  from 
food.  The  degree  of  bodily  temperature  in  fever  depends,  in  greater  or  less  measure,  upon  a  dis- 
turbance in  the  natural  play  between  the  functions  of  heat  production  and  heat  dissipation,  and 
is  not  an  accurate  measure  of  the  intensity  of  the  increased  chemical  movements  of  the  tissues." 
(Fever :  A  Study  in  Moibid  and  Normal  Physiology,  p.  240.  Bv  H.  C.  Wood,  A.M.,  M.D.  Pub- 
lished by  the  Smithsonian  Institution,  Washington,  D.  C,  1880.) 
1  Report  on  the  Causes  of  Infective  Diseases,  ls?5. 


104  INFLAMMATION. 

and  fever.  Abernethy,  Cooper,  Wilson  Philip,  Travers,  whose  doctrines  and 
phrases  were  on  the  lips  of  all  teachers,  and  dominant  in  the  schools,  referred 
the  obscure  phenomena  of  these  conditions  to  sympathy,  and  constitutional  irri- 
tation— somewhat  empty  phrases;  and  Hunter,  the  greatest  of  all,  evidently — 
to  us  of  this  generation — owes  his  pre-eminence  to  his  close  and  able  observa- 
tion of  Nature,  whom  he  questioned  through  experiments  upon  animals;  and 
to  his  fidelity  to  her  teachings.  This  most  fertile  of  all  our  sources  of  exact 
knowledge,  that  is,  knowledge  which  has  proved  reliable,  and  of  practical 
value  in  physiology  and  pathology,  namely,  experiments  upon  animals,  was 
undervalued  by  these  contemporaries  of  Brown  and  Broussais,  because  it  was 
the  fashion  to  believe  that  the  phenomena  ascribed  to  the  influence  of  the 
mind  and  nervous  system,  e.g.,  "sympathy,"  "constitutional  disturbance," 
and  "  constitutional  irritation,"  could  not  be  adequately  developed  in  the  lower 
animals,  and  that  the  knowledge  thus  acquired  could  not  therefore  be  profit- 
ably applied  to  man.  In  fact  there  are  a  few  of  the  descendants  of  these  sen- 
timental recusants  still  raising  their  voices  in  opposition  to  vivisection. 

If  we  omit  Hunter,  the  real  value  of  the  writings  of  the  authorities  just 
cited,  and  a  certain  charm  which  they  undeniably  possess,  will  be  found  in 
their  great  ability  as  clinical  observers  and  vivid  portrayers  of  the  symptoms 
of  disease,  and  not  in  the  interpretation  of  the  phenomena  they  witnessed. 
Their  opinions  were  too  often  warped  by  theories  prevalent  at  the  time,  which 
have  since  passed  away.  The  material  results  of  the  more  practical  researches 
of  the  present  generation,  promise  to  form  permanent  additions  to  our  know- 
ledge; as,  for  example,  the  fact  just  cited  from  Senator  that  the  injection  of  a 
little  fresh  pus  will  invariably  produce  fever  in  dogs,  or  that  of  the  production 
of  more  intense  and  fatal  fever  by  injection  of  putrid  matter,  as  proved  by 
Billroth  and  O.  Weber.  But  it  is  still  regarded  as  possible  that  substances 
may  be  elaborated  within  the  organism,  by  abnormal  chemico-vital  changes, 
under  the  influence  of  temporarily  perverted  nervous  action,  which  may  give 
rise  to  fever,  or  to  inflammation,  as  certainly  as  the  injection  of  fresh  pus  be- 
neath the  skin,  or  of  putrid  matter  into  the  veins.  The  clinical  facts  are  undis- 
puted that  the  simple  passage  of  a  sound  through  the  urethra  may  cause  a 
chill  and  fever,  and  that  a  sudden  fright  may  so  affect  the  quality  of  a  nurs- 
ing woman's  milk  as  to  produce  a  poisonous  effect  upon  the  nursling.  If  an 
influence  transmitted  through  nerves  is  competent  to  cause  a  change  in  a 
glandular  secretion,  begetting  a  poison,  why  may  not  the  blood  be  similarly 
affected  in  the  collapse  following  a  severe  injury,  in  which  the  generation  of 
nerve  force  by  nerve  cells  is  temporarily  suspended  ?  It  is  not  easy  to  submit 
such  a  question  to  the  test  of  experiment,  and  it  is  not  desirable  to  speculate; 
but  it  is  certainly  wise  not  to  lose  sight  of  these,  and  similar  phenomena,  as 
bearing  upon  the  causation  of  fever.1 

Mr.  Savory  has  quite  recently  entered  a  plea  for  consideration  of  the  claims 
of  the  nervous  system  as  bearing  upon  "  constitutional  disturbance,"  which 
may  possibly  be  referred  to  with  profit  in  this  connection.  This  eminent 
surgeon  contends  that  fever  may  arise  from  "nervous"  as  well  as  from  "ma- 
IcniiI"  sources,  and  that  the  formsof  fever  thus  produced  present  many  symp- 
toms in  common,  such  as  malaise,  and  rise  in  temperature ;  but  that,  where 
there  is  actual  blood-poisoning,  chills  and  sweats,  with  great  and  sudden  rises 

1  In  his  "  Ti<'f;mis  snr  la  Chaleur  Animale"  (Paris,  1876,  p.  445),  Claude  Bernard  concludes  that 
fever  is  nothing  more  than  an  exaggeration  of  the  physiological  phenomena  of  comhustion,  in 
consequence  of  interference  with  the  nerves  whose  office  it  is  to  control  and  regulate  these  pheno- 
mena. This  interference  may  !><■  reflex — as  from  a  wound  or  injury  ;  or  direct — as  from  section 
of  the  spinal  cord.  On  this  point  Prof.  Wood  (ui  supra)  concludes  that  "the  maintenance  of  the 
normal  temperature  and  its  rhythm  is  dependent  upon  the  nervous  system  which,  within  certain 
limits,  controls  both  the  production  and  dissipation  of  animal  heat." 


TRAUMATIC    OR    INFLAMMATORY    FEVER.  105 

of  temperature  are  present,  ending  in  congestion,  inflammation,  and  suppura- 
tion.1 

Aided  by  clinical  evidence,  we  may  conclude,  concerning  the  duration  of 
ordinary  traumatic  or  inflammatory  fever,  that  whether  it  arises  from  a  ner- 
vous, or  a  material  infective  cause,  or  from  a  combination  of  both,  in  the  great 
majority  of  cases  it  tends  to  get  well  spontaneously,  in  a  few  days;  the  vital 
powers  being  competent  to  set  to  rights  the  nervous  constitutional  disturbance, 
or  to  resist  and  prevent  the  propagation,  within  the  organism,  of  any  material 
or  infective  fever-producing  agents.  This  point,  that  is,  the  tendency  of 
traumatic  fever  to  spontaneous  and  speedy  recovery,  should  be  clearly  con- 
ceived, in  view  of  its  bearing  upon  the  question  of  treatment. 

In  accordance  with  the  doctrine  of  the  day  already  recognized,  and  leaving 
nervous  influence  out  of  the  question,  the  theory  which  best  explains  the  oc- 
currence of  traumatic  fever  is  the  absorption  of  poisonous  material  from  the 
wound  into  the  circulating  current,  the  presence  of  which  poisonous  material 
in  the  blood  causes  its  rise  of  temperature.  If  the  traumatic  fever  persist 
beyond  the  five  or  six  days  assigned  as  its  usual  duration,  or  if  it  recurs  in 
the  form  of  u  secondary"  fever,  the  most  probable  explanation  of  these  pheno- 
mena will  be  found  in  lack  of  power  in  the  organism  to  prevent  the  propaga- 
tion within  it  of  the  infective  material. 

The  terms  infective  and  non-infective,  introduced  by  Simon  and  Sanderson, 
have  been  so  generally  adopted  in  treating  of  surgical  inflammations  and 
fevers  as  to  require  special  definition.  They  involve  a  belief  in  a  simple 
form  of  inflammation  which  never  occurs  without  a  cause,  and  which  tends 
to  disappear  spontaneously  as  soon  as  its  cause  is  withdrawn.  "An  inflam- 
mation," says  Sanderson,2  "  which  is  more  or  less  exactly  limited  in  duration 
and  extent  by  the  limits  of  the  injury  which  has  caused  it,  may,  with  scien- 
tific precision,  be  designated  a  simple  or  normal  inflammation,"  that  is,  non- 
infective.  On  the  contrary,  "  an  inflammation  which  spreads  and  endures  beyond 
the  direct  and  primary  operation  of  its  cause,  which  induces  similar  inflam- 
mations in  other  parts,  and  disorders  the  vital  functions  of  the  whole  body, 
has  in  it  something  beyond  the  effects  of  the  injury,  and  may  be  properly 
termed  infective. ,"3  In  the  latest  English  systematic  work  on  pathology4  this 
is  spoken  of  as  "  one  of  the  most  important  divisions  of  inflammation ;" 
and  it  is  stated  that,  "  in  all  infective  inflammations  the  formation  of  the 
infective  substance  appears  to  be  due  to  the  presence  of  minute  organisms, 
these  organisms,  in  the  ordinary  non-specific  inflammations,  being  the  com- 
mon septic  bacteria."  It  cannot  be  said  to  be  demonstrated  that  the  infective 
properties  undoubtedly  possessed  by  fresh  healthy  pus,  as  the  typical  product 
of  inflammation,  are  due  to  micro-organisms.     If  so,  the  vital  quality  which 

1  In  his  opening  address,  as  President  of  the  Surgical  Section  of  the  British  Medical  Association, 
in  August,  1880,  Mr.  Savory  expresses  himself  as  follows  :  "  For  many  years  the  helief  prevailed 
that  disturbance  of  the  whole  body,  or  the  illness  produced  by  local  mischief,  was  evoked  through 
the  nervous  system,  and  hence  the  phrases  'sympathetic  inflammatory  fever,'  and  'constitu- 
tional irritation  ;'  and  this  great  doctrine  naturally  grew  in  force  as  the  functions  of  the  nervous 
system  came  to  be  better  understood.  The  discovery  of  reflex  function  went  very  far  to  explain 
tin  mode  of  action  of  the  nervous  system  as  the  channel  of  sympathy  between  the  various  struc- 
tures and  organs  of  the  body.  But  then  came  the  knowledge  of  what  is  now  known  as  '  blood- 
poisoning;'  and  from  the  time,  not  far  distant,  when  this  first  dawned  on  the  minds  of  surgeons, 
it  has  become  so  rapidly  developed  that  now  it  threatens  to,  nay  actually  does,  exclude  the  elder 
view  ;  so  that  with  many,  at  the  present  time,  constitutional  disturbance,  in  this  relation,  means, 
always,  the  phenomena  of  blood-poisoning,  in  some  one  or  other  of  its  various  forms."  He  then 
proceeds  to  show  that  both  these  forms  of  constitutional  disturbance  occur,  and  that  although 
they  are  often  confused,  it  is  of  the  highest  importance  to  distinguish  each  of  them. 

2  Report  of  an  Experimental  Study  of  Infective  Inflammation,  1S72,  ».  48. 

3  Ibid.  p.  49.  in 

cq.Au  1,ltrodu(;tiori  to  Pathology  and  Morbid  Anatomy,  p.  215.  By  T.  Henry  Green,  etc.  London, 
1881. 


106  INFLAMMATION. 

enables  a  healthy  organism  to  resist  disease  is  competent  to  prevent  their 
multiplication ;  for  the  infective  quality,  as  in  Senator's  clogs,  is  not  always 
persistent.  But  this  reasoning  would  not  apply  to  the  inoculations  of  mice 
by  the  septicemic  bacillus,  as  recently  described  by  Koch.  Thus  the  exist- 
ence of  an  indefinite  number  and  variety  of  infective  agents  is  again-  suggested 
as  probable. 

The  preceding  remarks  include  all  that  can  be  properly  said  here  con- 
cerning the  more' serious  forms  of  surgical  fever.  When  the  ordinary  trau- 
matic or  inflammatory  febrile  movement  begins  to  assume  more  grave  symp- 
toms, and  persists,  taking  on  the  aspect  of  what  the  older  surgeons,  after 
Abernethy,  called  "  irritative  fever,"  with  a  dry  tongue,  more  rapid  pulse, 
more  altered  aspect,  and  more  positive  emaciation,  and  possibly  diarrhoea, 
with  or  without  a  coincident  unhealthy  condition  of  the  wound,  and 
with  efficient  provision  for  drainage  of  the  wound — for  this  category  of 
symptoms  we  have  no  more  probable  explanation  to  offer  than  blood- 
poisoning.  When  putrescent  material  has  been  absorbed  into  the  blood, 
in  larger  quantity  than  the  organism  can  resist  or  throw  off,  as  from  a  con- 
tused or  unhealthy  wound  from  which  there  has  been  no  ready  avenue  of 
escape  by  drainage,  the  symptoms  which  have  been  ascribed  to  traumatic 
fever  become  intensified  in  the  manner  just  described  ;  then  septic  poisoning 
has  almost  certainly  taken  place,  and  the  condition  of  the  patient  comes  within 
the  definition  of  septicemia.  Or,  after  an  interval  during  which  the  trau- 
matic fever  may  have  almost  or  entirely  ceased,  during  the  second  week  after 
the  injury,  or  later — even  as  late  as  the  second  month — the  wound,  mean- 
while, showing,  perhaps,  no  serious  change  from  a  healthy  aspect — a  chill 
may  suddenly  occur,  followed  by  profuse  sweating  and  the  •characteristic  chill- 
recurrence  of  pycemia. 

Under  the  titles  of  septicaemia  and  p3^8emia,  these  phases  of  surgical  fever 
will  form  the  subject  of  a  separate  article. 


Inflammatory  Exudations. 

Clinically,  there  are  conditions  and  appearances  of  surgical  disease  resulting 
more  or  less  directly  from  the  presence  of  inflammation,  and  belonging  to  the 
category  of  its  symptoms,  which  are  caused  by  transudation  or  exudation  of 
materials  through  the  capillary  vessels.  Exudation  has  been  aptly  described 
as  the  connecting  link  between  the  infra-vascular  and  extra-vascular  manifes- 
tations of  inflammation ;  and  it  has  also  been  spoken  of  as  the  material  limit 
by  which  hypersemia  is  distinguished  from  true  inflammation.  The  mate- 
rials which  exude  through  the  walls  of  the  capillary  vessels,  vary  much  in 
character.  They  appear  on  the  surface  of  membranes,  as  in  diphtheria;  in 
the  interior  of  the  body, as  in  local  oedema,  or  in  hydrocele;  or  on  the  surface 
of'  recent  wounds,  as  in  the  form  of  plastic  lymph,  where  the  exudation  tends 
distinctly  to  the  formation  of  new  tissue.  Pathology  does  not  explain  the 
difference  between  transudation  and  exudation  with  sufficient  accuracy  to 
justify  an}-  clear  or  positive  distinction  between  the  terms.  As  a  rule,  the 
more  fluid  transudations  consist  of  a  phosphatic,  saline  liquid,  containing 
albumen  in  variable  proportion,  together  with  some  few  leucocytes  and  red 
blood-corpuscles,  and  they  are  ascribed  to  mechanical  hypersemia,  or  to  in- 
flammation of  a  low  grade;  whilst  the  exudations,  containing  solid  elements, 
e.g.,  white  blood-corpuscles  in  any  quantity,  and  fibrin — or  the  materials 
capable  of  readily  forming  it-  and,  possibly,  other  organic  products,  are  desig- 
nated as"  inflammatory,  and  ascribed  to  a  more  positive  condition  of  inflam- 
mation. 


INFLAMMATORY    EXUDATIONS.  107 

In  all  cases  these  exudations  are  derived  from  the  blood.  An  apparent 
exception  is  the  cell  germination  that  takes  place  so  actively  outside  of  the 
vessels,  either  of  wandering  cells  or  tissue  cells,  when  stimulated  by  the  direct 
contact  of  the  capillary  exudation.  As  a  general  rule,  afflux  of  blood  causes 
capillary  distension,  and,  as  a  result,  exudation  through  the  capillary  walls 
follows — a  sweating — as  the  term  implies  ;  or,  capillary  distension  from  me- 
chanical obstruction,  as  from  a  tight  bandage,  may  be  followed  by  a  similar 
result.  A  collection  of  fluid  in  the  meshes  of  the  subcutaneous  connective 
tissue  constitutes  oedema  ;  and  this  fluid  may  be  thin  and  watery,  or  rich  in 
albumen. 

Passive  exudation  through  the  walls  of  capillaries  altered  by  malnutrition, 
as  in  convalescence  from  acute  disease,  will  be  reabsorbed  by  the  lymphatics 
as  the  quality  and  tone  of  the  vascular  walls  is  restored ;  but  the  more  active 
exudation  through  over-distended  capillaries  whose  walls  are  altered  by  acute 
or  persistent  inflammation,  will  be  more  likely  to  go  on  to  tissue  formation, 
or,  this  failing,  to  suppuration.  Organic  chemistry  has  not  as  yet  taught  us 
enough  concerning  the  organic  constituents  of  these  so-called  inflammatory 
exudations  to  aid  us  in  classifying  them.  The  microscope  has  done  some- 
thing more  ;  but  our  knowledge  of  the  subject,  for  practical  purposes,  is  far 
from  complete.  Clinical  illustrations  of  their  different  forms  may  serve  to 
explain  certain  symptoms  and  phases  of  the  inflammatory  condition. 

The  cardinal  symptom  of  swelling  is  for  the  most  part  due  to  exudation. 
Under  some  circumstances,  as,  for  example,  after  certain  poisoned  wounds,  it 
is  so  rapid  and  extensive  as  to  suggest  that,  if  not  purely  serous,  the  poison 
must  have  suddenly  altered  the  walls  of  the  capillary  bloodvessels  as  well  as 
their  contents.  And  yet  the  sudden  and  rapid  swelling  that  sometimes  fol- 
lows the  sting  of  a  Wasp,  or  the  bite  of  a  rattlesnake,  may  subside  in  a  limited 
time  and  leave  scarcely  a  trace.  The  swelling  of  the  leg  that  takes  place 
during  the  growth  of  a  popliteal  aneurism,  is  at  first,  apparently,  simple 
oedema ;  but  the  leg  subsequently  becomes  warmer  than  natural,  and  brawny 
to  the  feel,  as  though  the  exudation  were  becoming  organized;  and,  in  view 
of  the  slow  recovery  from  this  condition  after  the  aneurism  has  been  cured, 
as  though  by  atrophy  of  the  new  tissue,  it  would  seem  that  this  apparently 
inflammatory  condition  has  really  been  caused  by  the  blood-stagnation.  A 
similar  brawny  thickening  of  the  legs  occasionally  follows  the  oedema  due  to 
hepatic  disease,  to  obesity,  to  failure  of  the  heart's  action  from  age;  and  it 
sometimes  accompanies  varicose  ulcers.  Although  mainly  the  result  of 
mechanical  hyperemia,  the  swelling  is  often  attended  by  increase  of  heat. 

Under  the  name  of  acute  oedema,  Sir  B.  C.  Brodie  described  a  rapid  swell- 
ing of  the  scrotum  by  infiltration  of  its  lax  subcutaneous  connective  tissue, 
causing  gangrene  of  the  integument,  apparently  by  cutting  off  its  blood- 
supply  through  over-stretching  of  its  nutritive  vessels.  This  was  probably 
an  acute  necrosis  of  the  connective  substance,  such  as  occurs  in  phlegmonous 
erysipelas.  The  fluid  of  an  ordinary  hydrocele  is  slightly  viscid  and  sticky, 
of  a  light  amber  color,  with  an  alkaline  reaction.  It  is  so  rich  in  albumen 
that  the  addition  of  nitric  acid  will  often  convert  the  fluid  into  a  solid  mass, 
by  neutralizing  the  soda  which  keeps  the  albumen  in  a  fluid  state. 

Serous  exudation  oceurs  more  readily  in  localities  where  the  bloodvessels 
are  surrounded  by  lax  connective  tissue.  Hence  the  danger  of  infiltration  of 
the  thyro-aiy  tenoid  folds,  and  consequently  of  obstruction  of  the  glottis — an 
example  of  the  oedema  always  present  in  a  greater  or  less  degree  in  the  meshes 
of  the  connective  tissue  of  the  outlying  area  surrounding  a  focus  of  inflam- 
mation. When  confined  to  a  limited  surface,  this  form  of  exudation  consti- 
tutes a  valuable  indication  of  the  presence  of  an  abscess  beneath.    It  has  been 


108  INFLAMMATION. 

called  collateral  oedema,  and  its  fluid  contains  white  cells  and  iibrogenous 
material. 

Of  these  so-called  serous  exudations,  it  is  stated  by  a  recent  authority1  that 
the  assertion  that  they  contain  only  dissolved  albumen  "  has  been  assumed, 
rather  than  chemically  demonstrated.  In  reality,  these  fluids,"  exuded 
mostly  under  the  influence  of  obstructive  hyperemia,  or  a  low  grade  of 
inflammation,  "  almost  always  contain  variable  quantities  of  iibrogenous 
matter,  of  fibrin,  or  of  mucus,  according  to  the  part  affected."  In  this  way 
we  explain  the  occasional  coagulation  of  the  exudation  following  a  blister,  and 
the  coloration  sometimes  caused  by  the  presence  of  red  corpuscles  or  of  their 
coloring  matter  in  a  state  of  solution.  The  free  watery  discharge  from  the 
nose  after  "  taking  cold,"  by  which  the  congested  Schneiderian  membrane 
relieves  itself,  often  leaves  the  handkerchief  stiff  as  if  it  had  been  starched. 

The  distended  bloodvessels  in  inflammation  not  unfrequently  relieve  them- 
selves entirely  and  finally  by  exudation,  thus  bringing  the  crisis  to  a  close. 

In  a  case  of  abdominal  dropsy,  which  followed  peritonitis  after  a  miscarriage,  the 
patient  experienced  a  complete  cure  by  tapping.  She  returned  some  months  later  with 
no  fluid  whatever  in  the  peritoneal  cavity ;  but  there  was  a  hernial  protrusion  at  each 
femoral  opening,  and  a  third  at  the  umbilicus. 

In  this  case  the  peritonitis  had  evidently  relieved  itself — had  "terminated," 
technically — by  free  serous  exudation.  In  an  ordinary  gum-boil,  the  intense 
pain  usually  ceases  as  soon  as  the  external  swelling  begins. 

The  quantity  of  the  apparently  watery  exudation  which  escapes  from  the 
cut  surfaces  after  an  amputation,  subsequent  to  the  arrest  of  hemorrhage,  is 
very  considerable  ;  after  an  amputation  at  the  hip-joint,  it  has  been  estimated 
at  from  a  pint  to  twenty  ounces.  It  is  generally  tinged  by  dissolved  blood- 
clot,  and  often  stains  and  saturates  the  dressings  so  as  to  suggest  the  idea  of 
hemorrhage.  It  is  not  for  us  to  determine  the  source  of  the  fibrin  which 
constitutes  so  large  a  proportion  of  the  coagulum  deposited  by  this  exudation. 
Organic  chemistry  has  left  this  question  still  in  the  region  of  theory.  It 
evidently  approaches  in  its  nature,  or  is  identical  with,  what  is  styled  by  a 
recent  authority2  "the  well-known  inflammatory  effusion,"  and  is  derived 
directly  from  the  liquor  sanguinis,  to  which  it  approaches  in  quality.  This 
exudation,  according  to  the  same  authority,  contains  "  more  albumen,  phos- 
pl uitos,  and  carbonates"  than  serous  exudations,  and  "has  a  much  greater 
tendency  to  coagulate,  due  to  the  white  corpuscles  it  contains  ;"  forming  thus 
a  hot-bed  or  compost  admirably  suited  for  promoting  cell  germination,  and 
for  furnishing  nutritive  materials  for  young  cells.  The  white  corpuscles  are 
regarded  as  emigrants  or  wandering  cells  which  have  escaped  through  the 
capillary  walls.  It  has  been  observed  that  the  exudation  in  inflammation 
which  occurs  early  is  always  more  fluid;  at  a  later  period  it  contains  more 
cells. 

The  exudation  in  healthy  or  constructive  inflammation,  generally  called 
'plastic  or  ctunjalable  lymph,  which  makes  its  appearance  on  the  surface  of  a 
recent  wound,  or  in  the  form  of  swelling  around  an  inflammatory  focus,  is, 
as  lias  just  been  stated,  a  bland  and  unirritating  product  of  the  nutritive 
machinery  ;  its  obvious  use  is  to  aid  in  forming  a  growth  of  new  tissue  for  a 
reparative  purpose.  This  purpose  may  find  its  result  in  the  organization  of 
cicatricial  tissue,  whereby  a  breach  of  continuity  is  healed;  or  in  forming  a 
limiting  barrier  to  suppuration,  which  is  always,  in  some  degree,  destructive; 

'  Cornil  and  Ranvier,  Manual  of  Pathological  Histology.     Philadelphia,  1880. 
2  Green,  ut  supra. 


I 


INFLAMMATORY    EXUDATIONS.  109 

or  in  aiding  the  separation  of  parts  which  have  lost  their  vitality.  In  the 
attainment  of  these  objects,  the  organization  of  a  new  growth  of  tissue  is 
indispensable.  When  this  tendency  to  organization  is  opposed  by  any 
obstacle,  as  where  the  cicatrization  of  a  wound  is  prevented  by  the  presence, 
for  example,  of  a  sequestrum  of  bone  not  yet  separated,  then  the  new  growth 
remains  indefinitely,  or  until  the  obstacle  is  removed,  in  the  inchoate  stage 
of  indifferent  or  granulation  tissue,  and  the  redundant  supply  of  exudative 
material  is  wasted  in  the  form  of  pus. 

There  are  varieties  of  inflammatory  exudation  closely  allied  to  plastic  or 
coagulable  lymph,  if  not  identical  with  it,  and  ecpially  remarkable  for  their 
prompt  tendency  to  organization,  which  are  encountered  especially  in  wounds 
and  inflammations  of  serous  membranes.  The  apposition  of  serous  surfaces 
after  injury  is  immediately  followed,  under  favorable  circumstances,  by 
adhesive  inflammation;  and  this  means  the  organization,  in  plastic  lymph,  of 
a  new  growth  of  tissue  which  forms  a  bond  of  union  between  them.  The 
"  false  membranes,"  so  often  found  in  the  shape  of  abnormal  bands  of  tissue 
binding  together  free  surfaces  of  the  pleura  or  of  the  peritoneum,  have  the 
same  origin.  They  are  the  result  of  constructive  inflammation  following 
some  injury,  which,  but  for  the  binding  and  restraining  influence  of  the  new 
formation,  would  have  gone  on  to  the  destructive  phase,  that  is,  to  pus  forma- 
tion. In  still  more  purely  fibrinous  exudations,  their  coagulation  is  said  to 
take  place  suddenly  and  in  successive  layers.1  The  dense,  bulky,  sometimes 
stratified  layers  of  fibrous  tissue  in  which  the  testis  is  found  enveloped  after 
an  old  injury,  are  sometimes  organized  blood-clots  within  the  cavity  of  the 
tunica  vaginalis,  and  sometimes  organized  exudation  from  the  surface  of  this 
membrane,  by  which  it  has  become  enormously  thickened. 

In  a  man  of  35,  whose  testicle  had  been  suspected  to  be  the  seat  of  malignant  disease, 
but  who  had  a  previous  history  of  contusion  and  consequent  hematocele,  a  healthy 
testicle  was  found  in  a  cavity  lined  by  what  seemed  to  be  tunica  vaginalis,  also  appa- 
rently healthy,  and  containing  no  appreciable  fluid,  the  walls  of  Avhich  were  an  inch  in 
thickness  throughout  its  whole  extent,  and  resembled  cicatricial  tissue. 

A  similar  mechanism  has  been  assigned  as  an  explanation  for  the  appear- 
ances often  presented  in  the  interior  of  the  sac  of  a  cured  aneurism.  They 
are  described  by  Robin2  as  u eaillots  actifs  jibrineux"  in  contradistinction  to 
the  soft  spongy  coagula  which  are  liable  to  form  in  aneurisms,  and  which 
possess  no  curative  value. 

Inflammatory  exudations  from  the  free  surfaces  of  mucous  membranes  are 
said  by  Cornil  and  Ranvier3  to  contain  mucus,  and  a  substance  called  mucin 
which  appears  in  the  form  of  filaments,  insoluble  in  acetic  acid,  and  which 
"  may  form  thick  layers  upon  the  surface  of  articular  cartilages,  notably  in 
the  case  of  white  swellings." 

What  is  called  croupous  exudation,  as  met  with  on  the  surface  of  mucous 
membranes  in  the  air  passages,  in  the  bladder,  and,  somewhat  rarely,  in  the 
intestines,  is  said  to  consist  of  filaments  of  fibrin,  and  sometimes  of  mucin, 
felted  together  with  pus  corpuscles  and  epithelial  cells — according  to  the  re- 
gion— in  their  interstices.  The  false  membranes  of  true  croup,  according  to 
the  best  authority,4  are  not  composed  of  true  fibrin,  but  of  altered  and  over- 
grown epithelial  cells.  Fibrin  is  present  in  the  exudation  from  an  inflamed 
mucous  membrane  only  when  its  epithelium  has  been  partially  or  completely 
destroyed.5 

1  Cornil  and  Ranvier,  op.  cit.,  p.  64.     Philadelphia,  1880. 

2  Leqons  sur  les  humeurs.  3  \Jt  supra. 

4  E.  Wagner,  Manual  of  General  Pathology.     New  York,  1876. 

5  Weigert,  Article  on  Inflammation.  Real-encyclopsedie  der  gesammten  Heilkunde,  Band  i. 
S.  642. 


110  INFLAMMATION. 


Plastic  or  Coagulable  Lymph. 

To  return  to  the  well-known  inflammatory  effusion  which  exudes  from 
recently  divided  living  surfaces,  and  deposits  upon  them  the  plastic  or  coagu- 
lable lymph  by  the  organization  of  which  their  union  is  effected,  this  form 
of  exudation,  and  the  steps  by  which  it  undergoes  the  organizing  process,  are 
worthy  of  careful  study.  It  is  the  characteristic  product  of  the  "  adhesive" 
inflammation  of  Hunter,  the  normal  type  of  the  true,  healthy,  constructive 
process.  Hunter  describes  the  aspect  presented  by  the  pale  jelly-like  coagu- 
lable lymph  as  it  appeared  to  his  unaided  eye  upon  an  exposed  surface  of 
bone ;  he  could  easily  have  wiped  it  away,  but  did  not ;  the  next  day,  to  his 
surprise,  it  had  become  pinkish  in  color,  and  bled  when  touched  by  the  probe. 
It  had  become  organized.  The  mechanism  of  this  curious  change — one  of 
the  changes  which  constitute  the  condition  of  inflammation:  that  is,  the 
organization  of  plastic  lymph,  which  histology  and  embryology  have  since 
rendered  plain  to  us — it  is  the  surgeon's  duty  to  supervise;  and  to  do  this 
intelligently  he  must  be  familiar  with  it.  Hunter  wisely  withheld  his  hand 
and  watched  the  process  with  the  eye  of  genius.  At  the  end  of  another 
century,  with  the  advantage  of  the  microscope,  we  enjoy  the  privilege  of 
seeing  more  clearly  the  minute  appearances  which  attend  the  organization  of 
plastic  lymph,  and  can  recognize  with  certainty  what  Hunter  only  assumed. 

The  substance  of  coagulable  or  plastic  lymph  affords  by  its  chemico-vital 
constituents  the  best  possible  pabulum  for  cell  germination  and  sustenance, 
and  the  leucocytes  or  white  corpuscles  already  present  in  it  begin,  at  once,  to 
germinate.  In  a  few  hours  after  the  receipt  of  a  wound,  the  process  of  cell 
germination  has  converted  the  jelly-like  material  deposited  upon  its  surface 
into  a  mass  of  granular  cells,  all  of  the  same  size,  and  so  numerous  as  to  touch 
each  other  on  all  sides,  leaving  only  minute  angular  interspaces  filled  with 
intercellular  substance.  These  granular  cells  are  minute  spherical  masses  of 
protoplasm,  called  by  Huxley  "embryonic"  cells.  He  gives  them  this  name 
because  they  are  the  first  formed  and  most  constant  features  that  make  their 
appearance  in  the  jelly-like  substance — plastic  lymph,  it  might  be  called — 
that  constitutes  the  human  embryo  when  it  first  becomes  manifest  under  a 
magnifying  power.  They  are  almost  if  not  quite  identical  with  white  blood 
corpuscles,  with  lymph  corpuscles,  with  young  pus  cells,  with  young  epithe- 
lium, with  so-called  granulation  cells,  and  with  young  connective  tissue  cor- 
puscles; and  to  all  these  cells,  undistinguishable  from  each  other  in  their 
earlier  stages  by  any  means  at  present  under  our  command,  the  common  ap- 
pellation of  leucocytes  or  indifferent  cells  is  applied  by  histologists. 

And  now,  as  soon  as  the  j^lastic  lymph  has  been  thus  converted  by  the  ger- 
minal ]  lower  into  a  mass  of  living  cells,  another  strange  phenomenon  takes 
place:  a  minute  stream  of  cells,  differing  in  appearance  from  those  just  de- 
scribed, may  be  seen  coursing  its  way  through  the  crowd  of  leucocytes,  which 
seem  lo  flatten  out  and  make  walls,  apparently  to  keep  the  slender  current 
within  bounds;  and  this  tiny  stream  of  pinkish  }Tellow  cells,  curving  upon 
itself,  assumes,  forthwith,  the  outline  of  a  loop.  It  is,  in  fact,  a  newly  formed 
capillary,  containing  red  blood-corpuscles,  which  are  readily  distinguishable 
as  such  by  their  faint  color,  and  their  characteristic  shape — that  of  flattened 
bi-concave  disks.  The  new  capillary  loops  shoot  into  the  cell  mass  from  the 
surfaces  of  the  recently  divided  tissue,  projected,  as  it  were,  from  its  over- 
distended  capillaries  by  a  process  of  budding  and  growth  of  new  vessels,  or 
by  simple  rupture  and  "channelling."  However  formed,  they  shortly  con- 
stitute myriads  of  delicate  connecting  threads  running  into  the  mass  of 
recently  germinated  cells  which,  thus  furnished  with  a  blood  supply,  begin 


PLASTIC    OR    COAGULABLE    LYMPH.  Ill 

to  undergo  another  change.  The  cells,  heretofore  "  indifferent"  embryonic 
corpuscles,  begin  to  alter  their  aspect,  and  to  develop  into  connective-tissue 
cells ;  the  intercellular  substance  undergoes  the  process  called  fibrillation ;  and 
thus  the  embryonic  substance  becomes  converted  into  young  connective  tissue. 

The  office  of  the  newly-formed  tissue  now  becomes  apparent:  it  is  truly 
connective,  for,  having  filled  the  breach,  it  straightway  draws  and  binds  to- 
gether the  opposite  sides  of  the  wound,  and  thenceforward  takes  the  name  of 
cicatricial  tissue.  Thus,  the  adhesive,  cement-like  material  furnished  by  the 
inflammatory  exudation  becomes  organized  into  new  tissue  that  forms  a  bond 
of  union  by  which  a  breach  of  continuity  is  healed. 

This  is  the  mechanism  by  which  constructive  inflammation  fulfils  its  repa- 
rative office  in  its  most  simple  and  typical  phase.  The  stages  of  the  process 
are  appreciable  by  the  naked  eye,  and  at  the  bedside,  by  the  symptoms 
already  detailed,  which  vary  in  intensity  according  to  the  size  and  depth  of 
the  wound.     The  result  constitutes  union  by  the  first  intention. 

The  cicatricial  bond  becomes  invested  with  epidermis  by  the  same  process 
of  cell  growth  and  development.  At  first  the  scar  is  redder  than  the  neigh- 
boring integument,  in  consequence  of  the  larger  proportion  of  vessels  carry- 
ing the  red  blood  necessary  for  its  organization  and  growth.  But  afterwards 
its  succulence  diminishes;  the  capillaries,  no  longer  required,  shrink  or  dis- 
appear; so  that  the  cicatrix  diminishes  in  bulk,  and  becomes  paler  in  color, 
forming,  after  the  primary  union  of  an  incised  wound,  a  simple  white  line,  in 
many  cases  scarcely  visible. 

In  the  case  of  an  abrasion,  or  a  surface  wound  of  limited  extent,  the  exuding 
plastic  lymph  dries  upon  the  raw  surface  when  it  is  left  at  rest  and  exposed 
to  the  dessicating  action  of  the  air,  and  covers  it  with  a  crust.  By  this  me- 
chanism, which  is  the  common  mode  by  which  Nature  cures  the  slighter 
wounds  of  animals,  a  tough  and  somewhat  flexible  scab  is  formed,  which  pro- 
tects and  seals  the  raw  surface  from  external  contact,  Beneath  this  natural 
dressing,  if  undisturbed,  the  breach  of  continuity  is  repaired  very  perfectly  by 
the  organization  of  plastic  lymph.  The  dried  scab,  in  due  time,  falls  sponta- 
neously, revealing  a  smooth,  slightly  reddish  surface  invested  with  epidermis 
which,  subsequently,  becomes  paler  in  color,  and  often  scarcely  distinguishable. 
This  is  a  mode  of  repair  in  which  the  symptoms  which  ordinarily  attend  in- 
flammation are  usually  very  slight,  and  often  seem  to  be  entirely  absent.  It 
is  called  healing  under  a  scab,  and  is,  in  fact,  Nature's  favorite  method  of  cure, 
and  should  always  be  promoted  when  circumstances  are  favorable. 

In  superficial  wounds  of  mucous  surfaces,  a  similar  prompt  result  of  con- 
structive inflammation  is  accomplished  under  the  sheathing  protection  of  the 
mucous  secretions.  Wounds  and  lacerations  of  internal  organs  often  leave 
cicatrices  behind  them,  discovered  on  post-mortem  examination,  as  the  only 
evidence  of  their  previous  existence.  A  rupture  of  the  tendo  Achillis,  or  a 
simple  fracture  of  bone,  undergoes  repair  by  the  process  of  tissue  formation 
just  described  as  "healing under  a  scab."  The  part  played  here  by  the  leuco- 
cytes which  germinate  in  the  plastic  lymph  justifies  the  title  conferred  upon 
them  of  "  indifferent"  cells,  for  they  develop  with  equal  facility  into  tendinous 
or  bony  substance,  as  into  connective  tissue. 

All  these  examples  of  the  inflammatory  process,  usually  spoken  of  as  "ad- 
hesive," "constructive,"  or  "reparative"  inflammation,  representing  the  mode 
in  which  are  cured  the  great  multitude  of  simple  lesions  which  never  come 
under  the  cognizance  of  the  surgeon,  serve  to  illustrate  the  natural  healing 
powers  possessed  by  the  organism.  It  is  only  when  this  benign  process,  which 
we  have  described  as  simply  an  unusual  effort  on  the  part  of  the  ordinary 
local  nutritive  apparatus,  is  interrupted  or  interfered  with  in  any  way,  that 


112  INFLAMMATION. 

we  are  liable  to  encounter  the  symptoms  of  the  more  serious  forms  of  inflam- 
mation which  have  been  designated  as  destructive.  The  more  common  sources 
of  interruption  to  the  normal  process  of  repair  have  been  already  enumerated, 
under  the  title,  heretofore  in  common  use,  of  "predisposing"  and  "exciting 
causes  of  inflammation."  Now  it  is  obvious  that  these  expressions  are  strictly 
correct  only  in  the  limited  sense  which  regards  the  causes  of  inflammation  as 
obstacles  to  the  continuance  or  completion  of  a  normal  process,  or  as  opening 
the  way  for,  and  favoring,  as  it  were,  the  bad  consequences  which  necessarily 
follow  stoppage  or  interruption  of  the  nutritive  machinery  of  a  part,  or  its 
failure  to  repair  an  injury  in  a  natural  way.  In  any  other  sense,  a  conclusion 
could  be  assumed  as  logical  that  these  causes  provoke  destructive  inflamma- 
tion as  an  essential  and  an  aggressive  disease,  a  doctrine  which  in  the  early 
part  of  this  article  was  distinctly  denied. 


Destructive  Inflammation.    Pus  Formation. 

In  accordance  with  this  view,  the  symptoms  of  destructive  inflammation, 
which  we  have  next  to  consider,  are  to  be  regarded  as  the  consequences  of 
some  cause  or  causes  which,  by  their  influence  upon  the  organism,  have  had 
the  effect  of  interrupting  or  impairing  normal  local  nutritive  action,  in  con- 
nection with  the  series  of  changes  following  injury.  This  doctrine  will  be 
illustrated  by  the  study  of  suppuration,  or  pas  formation,  the  most  common 
and  important  of  the  changes  liable  to  follow  injury.  Suppuration  is  prop- 
erly treated  of  as  a  symptom  of  inflammation  of  the  destructive  sort,  because, 
although  commonly  associated  with  the  mode  of  healing  by  granulation  and 
suppuration,  known  as  "healing  by  the  second  intention,"  it  never  takes  place 
without  a  distinct  and  positive  loss  of  substance.  Healing  by  the  adhesive 
process — "by  the  first  intention" — does  not  necessarily  involve  any,  or  an 
almost  imperceptible,  textural  loss;  but  whenever  pus  is  formed,  there  is 
at  least  an  equivalent  furnished  in  nutritive  material,  or  in  tissue  already 
existing. 

Suppuration  and  Granulation. — To  describe  the  mode  of  pus  formation  in 
its  most  common  aspect,  let  us  recur  to  the  condition  of  an  open  wound,  the 
.-i  i  rface  of  which  has  become  glazed  by  a  deposit  of  plastic  lymph,  but  in  which 
from  loss  of  substance,  or  the  presence  of  foreign  material  in  the  wound,  its 
surfaces  cannot  be  brought  together,  in  accurate  contact,  so  as  to  secure  union 
by  primary  adhesion.  Here  the  object  of  the  exaggerated  effort  on  the  part 
of  the  local  nutritive  apparatus  to  repair  the  lesion  in  the  most  simple  and 
effective  way,  is  rendered  unattainable;  the  purpose  for  which  the  inflamma- 
tory exudation  has  been  poured  out,  is  baulked.  But  Nature  has  other  re- 
sources  at  command  by  which  the  end  can  be  reached;  not  so  promptly  and 
readily,  with  more  delay  and  expense,  but  still  repair  of  the  injury  can  be  ac- 
complished. Her  next  effort  towards  this  end  is,  after  the  delay  of  a  day  or 
two,  and  with  a  certain  amount  of  local  soreness  and  swelling,  and  more  or 
less  general  disturbance  or  distress,  to  generate  a  red  velvety  surface  upon  the 
wound,  and  clothe  it  with  a  bland,  cream-like  yellowish  fluid.  Under  these 
new  conditions,  if  circumstances  are  favorable,  the  wound  goes  on  to  heal,  in 
the  manner  to  be  described.  The  soft  red  surface  is  coagulable  lymph  which 
has  become  organized  into  indifferent  or  embryonic  tissue — henceforward  to  be 
spoken  of  as  "  <jra nidation  tissue ;"  and  the  yellowish  bland  fluid  is  pus.  The 
nature  and  uses  of  these  "  products  of  inflammation"  we  have  next  to  examine. 

Although  generated  at  the  expense  of  some  local  and  general  disturbance 
to  the  organism,  it  is  to  be  noted  that  these  substances  obviously  have  a  pur- 


DESTRUCTIVE    INFLAMMATION PUS    FORMATION.  113 

pose,  which  is  reparative,  in  accordance  with  which  they  are  physically  and 
chemically  soft  and  bland ;  and  that  they  are  the  product  of  the  nutritive 
machinery  of  the  injured  part  by  a  natural  process  analogous  to  embryonic 
growth  and  development.  Granulation  tissue,  with  the  clinical  aspects  of 
which  the  surgeon  must  be,  of  necessity,  familiar,  consists  of  embryonic  cells 
and  a  network  of  capillary  loops  which  convey  to  it  a  steady  supply  of  nu- 
tritive material  from  the  blood.  It  is  equipped,  so  to  speak,  for  growth  and 
development  into  a  higher  form  of  tissue,  e.g.,  tissue  of  cicatrix;  but  when 
this  purpose  is  prevented,  or  when  it  becomes  unattainable,  the  neoplasm  is 
capable  of  supporting  itself  in  an  inchoate  condition,  as  simple  granulation 
tissue,  for  an  indefinite  time — of  which  we  have  an  illustration  in  the  walls 
of  an  old  sinus.  It  is  well  to  notice  that,  with  this  power  of  endurance,  the 
original  purpose  manifest  in  the  organization  of  this  curious  substance  is 
never  lost  sight  of;  it  is  ready  to  take  on  development  into  a  higher  form  of 
tissue  whenever  favorable  conditions  arise. 

In  its  physical  aspects,  granulation  substance  has  a  pinkish  color,  variable 
in  tint  according  to  the  quality  of  the  blood  circulating  in  its  vessels,  and  is 
jelly-like  in  consistence,  with  a  certain  degree  of  smoothness  and  firmness 
to  the  touch.  Its  surface,  when  healthy,  is  covered  with  small  conical  emi- 
nences called  granulations,  not  entirely  uniform  in  size,  in  which,  by  the  aid 
of  a  pocket  lens,  minute  vessels  can  be  distinguished.  The  latter  are  so  near 
the  surface  that  a  slight  touch  of  probe  or  needle  brings  a  drop  of  blood. 
Yellow  pus  is  seen  in  the  depressions  between  the  eminences.  These  vary  a 
good  deal  in  size  and  shape  as  well  as  in  color,  and,  inasmuch  as  their  aspect 
affords  an  unfailing  index  of  healthy  healing  power,  and  as  they  are  found 
on  all  healing  surfaces,  these  variations  are  worthy  of  close  observation. 

When  there  is  a  lack  of  vigor  in  the  tendency  to  grow  into  cicatricial 
tissue,  the  granulations  are  large  and  translucent,  and  the  pus  between  them 
is  pale  and  thin.  When  there  is  excess  of  inilammatory  action,  as  when  the 
part  has  been  subjected  to  motion  involving  friction,  or  to  irritating  dressings, 
they  become  abnormally  small,  and  their  color  is  vividly  red.  Subsequently, 
under  the  persistent  action  of  the  same  causes,  the  granulations  may  disappear 
at  points,  showing  grayish  spots  in  which  they  have  died,  or  smooth  patches  in 
which  they  have  ceased  to  grow.  Usually,  healthy  granulations  are  not  sen- 
sitive to  the  touch,  for,  although  full  of  bloodvessels,  they  contain,  as  yet,  no 
nervous  filaments,  although  the  contrary  is  asserted  by  Robin  and  others ;  it 
is  undoubtedly  true  that  in  certain  abnormal  conditions  they  become  exqui- 
sitely painful.  Individual  granulations  vary  in  size  and  shape,  even  upon 
the  same  surface.  They  are  sometimes  larger  at  the  apex  than  at  the  base, 
and  occasionally  will  be  found  cleft  at  their  summits  like  a  cauliflower. 

When  cicatrization  is  about  to  take  place,  and  its  consummation  is  pre- 
vented in  any  way,  granulations  in  some  cases  tend  to  increase  in  size,  and 
to  become  overgrown :  as  around  a  seton,  a  group  of  ligatures,  or  a  drainage 
tube;  or  in  a  wound  involving  the  sheath  of  a  tendon."  Under  these  circum- 
stances, a  number  of  overgrown  granulations  may  coalesce  and  form  a  pouting 
mass,  overhanging  the  edges  of  a  wound,  and  constituting  what  is  known 
popularl}'  as  "  proud  flesh."  These  redundant  granulations  are  generally  more 
pallid  and  flabby  than  those  of  healthy  type,  and  their  presence  always  indi- 
cates that  some  cause  is  obstructing  the  beginning  of  cicatrization. 

A  surface  of  granulations  undoubtedly  possesses  a  considerable  power  of 
absorbing  soluble  substances  brought  into  contact  with  it.  This  has  been 
already  asserted  in  connection  with  the  capacity  of  granulations  for  absorbing 
blood  poisons.  If  a  small  fragment  of  iodine  enveloped  in  cotton  be  placed 
upon  a  granulating  wound  under  a  watch-glass,  and  covered  in  carefully,  in 
a  very  short  time  chemical  reagents  will  reveal  the  presence  of  iodine  in  the 
vol.  i. — 8 


114  INFLAMMATION. 

urine.1  Where  an  animal  poison,  or  virus,  as,  for  example,  that  of  hospital 
gangrene,  or  of  the  contagious  venereal  ulcer  known  as  chancroid,  has  been 
brought  to  bear  upon  a  granulating  wound,  or  ulcer,  then  the  whole  process 
of  healing  by  granulation  is  blighted.  The  granulations  themselves  melt 
away,  or  die,  and  their  substratum  of  tissue  is  converted  into  what  is  called  a 
slough,  which  is  a  layer  of  dead  tissue — a  moist  eschar.  When  somatic  death 
takes  place  during  the  healing  of  an  open  wound,  its  granulating  surface  will 
be  found,  on  post-mortem  inspection,  to  have  mainly  disappeared.  It  is  re- 
placed by  the  glazed  surfaces  of  the  original  wound.  When  the  heart  ceases 
to  beat,  and  their  blood  supply  is  thereby  cut  off,  the  granulation  cells  shrivel 
and  dry  up,  or  melt  away  by  liquefaction.  The  latter  is  the  most  usual  mode 
of  death  of  the  leucocyte,  and  of  all  organic  cells. 

Thus  far  we  have  considered  the  physical  aspects  of  granulation  tissue,  but 
little  has  been  said  concerning  the  formation  and  discharge  of  pus,  which 
constitutes  so  prominent  a  feature  in  the  healing  of  open  wounds.  A  flow 
of  pus  goes  on  uninterruptedly  from  all  parts  of  the  surface  of  every  open 
wound  during  healthy  healing,  as  a  part  of  the  normal  process.  The  first 
appearance  of  pus  in  an  open  wound  marks  the  successful  organization  of  the 
plastic  lymph,  the  first  stage  in  healing  ;  it  coincides  with  the  heat  and  ten- 
sion of  the  wound,  and  the  febrile  movement  affecting  the  whole  organism 
which  has  been  already  mentioned.  As  soon  as  suppuration  has  fairly  made 
its  appearance,  the  swelling,  tension,  and  heat  of  the  wound  are  sensibly  re- 
lieved, and  the  increased  temperature  of  the  body  and  frequency  of  the  pulse, 
if  present,  generally  subside.  After  an  amputation,  where  the  wound  has 
remained  open,  and  its  progress  has  been  favorable,  the  soft  connective  and 
muscular  tissues  are  covered  with  granulations  in  from  three  days  to  a  week; 
but  the  harder  white  fibrous  aponeuroses  and  the  tendons  require  more  than 
double  this  time  ;  and  the  bone  may  remain  bare  and  white  for  three  weeks 
or  longer.  But,  unless  there  is  a  dead  portion  "to  be  cast  off,  even  these 
unpromising-looking  parts  become  in  time  invested  with  a  rosy  film  of 
organized  lymph,  and  now  the  whole  surface  of  the  wound  presents  an  uniform 
expanse  of  granulations. 

If  the  granulations  are  healthy,  this  is  the  propitious  moment  for  attempt- 
ing union  by  "  secondary  adhesion."  It  is  a  property  of  granulating  surfaces 
to  adhere  promptly  and  permanently  if  brought  together  accurately  and  held 
in  quiet  contact ;  and  this  property  of  healthy  granulations  is  taken  advan- 
tage of  by  the  surgeon  in  many  ways  in  order  to  expedite  healing.  Xow, 
when  secondary  adhesion  is  successfully  attained  thus  instantaneously,  what, 
in  this  event,  becomes  of  the  discharge  of  pus  ?  In  order  to  answer  this 
question  satisfactorily  we  must  first  study  somewhat  more  closely  the  inti- 
mate nature  of  pus,  and  learn  what  is  to  be  known  concerning  its  source  and 
its  significance. 

Physical  Qualities  of  Pus. — In  its  most  usual  form,  healthy  pus  is  a 
cream-like  fluid  of  a  yellowish-white  color,  tending  sometimes  to  assume  a 
pale  greenish  tint;  it  has  a  mawkish,  faintly  animal  odor;  a  slightly  saltish 
;iik1  rather  sweet  taste ;  an  unctuous,  soapy  feel ;  no  viscosity  or  stringiness  ; 
and  mi  alkaline  reaction.  Pus  is  constantly  presenting  variations  from  these 
normal  characteristics  according  to  the  circumstances  under  which  it  is  gene- 
rated,  the  tissues  at  the  expense  of  which  it  is  produced,  and  its  freshness  or 
age.  It  manifests  little  disposition  to  putrefaction,  even  at  the  temperature 
of  the  body,  as  long  as  the  air  has  no  access  to  it ;  and,  when  removed  from 

1  Lcgouest.     Dictionnaire  EncyclopeYlique.     Art.  "  Cicatrice." 


DESTRUCTIVE   INFLAMMATION — PUS    FORMATION.  115 

the  body  and  exposed  at  an  ordinary  temperature,  it  is  rather  slow  to  undergo 
change. 

When  allowed  to  stand  quietly  for  some  hours,  pus  gradually  separates 
into  two  portions:  one,  solid,  which,  under  the  influence  of  gravity,  sinks  to 
the  bottom  of  the  vessel ;  and  another,  liquid,  and  lighter  in  color,  which 
floats.  The  solid  portion  of  fresh  pus  consists  almost  entirely  of  leucocytes, 
which  are  here  called  j^^-corpuscles  ;  its  liquid  portion  is  a  serous  fluid 
known  as  liquor  puris.  In  normal  pus  of  average  quality,  its  solid  portion 
constitutes  about  twenty-rive  per  cent,  of  the  whole ;  three-quarters  of  its 
bulk  being,  therefore,  liquor  puris.  But  this  proportion  may  vary  greatly: 
in  most  cases,  by  diminution  in  .quantity  of  the  corpuscles.  Thus,  in  the 
thin,  serous,  watery  pus  that  comes  from  an  open  wound  on  the  eve  of  heal- 
ing— when  it  usually  presents  this  quality — or  in  that  furnished  by  an  indo- 
lent ulcer,  the  proportion  of  corpuscles  may  sink  as  low  as  two  or  three  per 
cent. ;  whilst  in  the  thick  unctuous  discharge  from  a  healthy  granulating 
wound,  or  an  acute  abscess,  it  may  rise  as  high  as  twenty-nine  per  cent,1 

The  presence  of  pus  of  good  consistence — the  "  laudable"  pus  of  the  older 
surgeons — indicates  the  existence  of  active  reparative  power.  Thin  pus 
means  just  the  contrary :  either  that  the  healing  process  has  reached  a  natural 
termination — a  cicatrix  being  about  to  close  in  the  suppurating  surface — or 
that  its  healthy  progress  is  otherwise  interfered  with  or  suspended.  When 
pus  is  formed  under  pressure,  as  in  the  antrum  of  the  upper  jaw,  or  in  abscess 
of  bone,  it  may  present  the  aspect  of  a  j'ellowish,  solid,  cheesy  mass,  the  com- 
pressed pus-cells  showing,  under  a  magnifying  power,  an  angular  outline. 
But  they  will  swell  in  water,  and  the  addition  of  acetic  acid  will  bring  out 
the  characteristic  nuclei.  Solid  pus  has  been  mistaken  for  tubercular  deposit, 
As  to  variations  in  color,  pus  sometimes  presents  a  deep  yellow  or  orange 
tint  from  bile,  or,  in  rare  cases,  on  dressings  long  unchanged,  it  shows  a  blue 
color,  which  is  caused  by  the  growth  of  a  minute  fungus  or  mould.  All  the 
other  tints  of  pus  come  from  the  coloring  matter  of  the  blood — haematoidine. 

Anatomical  Characteristics  of  Pus. — When  we  investigate  the  anatomi- 
cal characteristics  of  pus,  after  separating  its  solid  constituents  from  the  serum, 
we  find  that  more  than  nine-tenths  of  the  former  consist  of  leucocytes  or 
young  pus-cells.  These  latter,  in  freshly  formed  pus,  present,  under  a  mode- 
rate magnifying  power  (250  diameters),  the  granular  aspect,  and  also  the 
peculiar  amoeboid  movements,  of  vigorous  young  healthy  leucocytes.  In  pus 
which  has  been  collecting  in  an  abscess  for  several  days,  or  which  has  been 
discharged  from  the  body  for  a  few  hours,  these  movements  indicative  of  life 
are  no  longer  to  be  seen.  Under  these  circumstances,  the  pus-corpuscles  pre- 
sent themselves  as  cells  with  from  two  to  five  nuclei,  most  generally  three, 
and  these  form  a  cluster  resembling  a  clover  leaf.  This  is  considered  and 
pictured  as  the  most  characteristic  form  of  the  pus-corpuscle.  But,  whenever 
the  pus-corpuscle  presents  this  aspect,  it  is  no  longer  capable  of  amoeboid 
movements — it  is  dead.  A  film,  constituting  a  sort  of  cell-wall,  has  formed 
around  its  outer  surface ;  it  is  uniformly  round.  When  subjected  to  the 
action  of  dilute  acetic  acid,  it  dissolves — all  except  the  outer  film  or  cell-wall, 
and  the  central  trefoil-shaped  nucleiform  mass. 

These  two  varieties  of  pus-cells,  living  and  dead,  are  often  seen  mingled 
together  in  various  proportions  in  an  ordinary  specimen  of  pus.  In  pus 
which  has  been  formed  for  some  time,  and  confined  in  contact  with  the 
tissues,  there  are  also  found  larger  corpuscles,  overgrown,  as  it  were,  and 
stuffed  with  granules  of  fatty  matter  in  addition  to  their  nuclei ;  these  are 

1  Robin,  ut  supra. 


116  INFLAMMATION. 

simply  obese  pus-cells  which  have  been  overtaken  by  fatty  degeneration- - 
one  of  the  diseases  to  which  pus-cells  are  liable.  Minute  drops  of  free  oily 
substance,  also,  as  well  as  granular  debris,  are  almost  always  present  in  pus, 
derived  from  the  breaking  down  of  the  overgrown  granular  corpuscles  just 
mentioned,  or  from  neighboring  adipose  tissue.  More  rarely  the  delicate 
needle-shaped  crystals  of  the  fatty  acids — the  margaric  and  stearic — may  be 
detected.  It  is  the  presence  of  this  small  amount  of  fatty  matter  in  pus  that 
gives  it  the  odor,  when  boiled,  of  boiled  milk.  A  certain  portion  of  this 
fatty  matter  enters  into  combination  with  the  salts  of  potassium  and  sodium 
which  are  always  present  in  the  serum  of  pus ;  and  this  explains  its  soapy 
feci.  Cholesterine,  recognizable  by  its  broad  rhomboidal  crystalline  plates,  is 
also  sometimes  seen  in  pus,  especially  in  that  from  the  testes,  broad  ligaments, 
and  ovaries,  and  from  pelvic  and  psoas  abscesses. 

Amongst  the  accidental  elements  sometimes  recognized  in  pus  are  vibrios 
and  bacteria.  Here,  these  organisms  have  usualty  this  simple  signification, 
and  no  other,  namely,  that  the  pus  in  which  they  are  found  is  about  entering 
into  decomposition;  that  its  vital  quality  is  at  a  low  ebb,  and  that  chemical 
forces  are  in  the  ascendant.  Red  blood-globules  are  constantly  met  with  in- 
termingled with  the  cells  of  pus;  they  come  from  the  rupture  of  capillary 
vessels,  from  inflammatory  over-distension.  The  admixture,  in  larger  propor- 
tion, of  both  blood  and  oily  matter  with  pus,  is  often  apparent  to  the  naked 
eye,  as  when  the  contents  of  an  abscess  have  been  evacuated  by  incision  through 
vascular  and  fatty  tissues.  In  pus  which  has  formed  in  contact  with  diseased 
bone,  minute  granules  of  bone-earth  are  sometimes  found.  Under  all  circum- 
stances, the  debris  of  the  tissue  at  the  expense  of  which  pus  is  formed,  is  liable 
to  be  present  in  it,  in  larger  or  smaller  masses. 

The  Liquid  Portion  of  Pus. — Liquor  puris,when  separated  from  the  solid 
materials  of  pus  by  careful  filtration,  is  a  clear,  slightly  alkaline,  albuminous 
liquid  containing  no  solid  particles  whatever.  Its  alkaline  reaction  is  due  to 
the  presence  of  salts  of  sodium  with  excess  of  base;  it  also  contains  chloride  of 
s<  ulium,  and  the  phosphates  of  sodium,  lime,  and  magnesium— more  of  the  two 
latter  when  the  pus  has  formed  in  contact  with  bone.  The  addition  of  nitric 
acid  will,  therefore,  always  cause  a  precipitate  of  albumen  from  the  filtered 
scrum  of  pus.  In  decomposition,  or  whenever  ammonia  is  present,  the  well- 
known  large  prisms  of  the  triple  phosphate  of  ammonium  and  magnesium  can 
be  detected  in  pus.  They  are  generally  present  in  the  dried  pus  that  collects 
about  a  wound.  In  the  exceptional  cases  in  which  pus  reddens  litmus  paper, 
there  is  rancidity  in  consequence  of  the  generation  of  butyric  and  other  fatty 
acids.  When  liquor  potassce  or  aqua  ammoynce  is  added  in  a  very  moderate 
proportion  to  pus  in  a  test-tube,  and  the  two  substances  are  shaken  together, 
a  curious  semi-solid  translucent  mass  results,  which  has  the  aspect  and  consist- 
ence  of  dense  mucus.  The  pus-cells  are  dissolved  by  the  alkali,  which  also 
reacts  upon  the  albuminous  compound  in  the  liquor  puris.  The  slimy  sub- 
stance that  forms  when  the  parts  around  an  open  wound  are  washed  with 
soap  and  water,  is  a  result  of  this  peculiar  reaction  of  pus  with  the  alkali  of 
the  soap.  It  also  explains  the  characteristic  ropy  mucoid  discharge  from  the 
bladder,  in  cystitis,  whenever  ammonia  is  set  free  in  the  urine. 

The  Sources  oe  Pes. — We  have  next  to  consider  the  source  of  pus.  The 
firsl  question  thai  presents  itself  is  this:  What  is  the  force  that  brings  leuco- 
cytes to  the  surface  of  a  granulating  wound  to  be  discharged  thence  in  the 
form  of  pus?  This  force  seems  to  be  found  in  the  liquid  exudation,  the  supply 
of  which  from  the  capillaries,  both  newly  formed  and  old,  is  copious  and  con- 
tinuous, until  arrested  by  the  cicatrization  of  the  wound.     The  afflux  of  blood 


DESTRUCTIVE   INFLAMMATION — PUS   FORMATION.  117 

inaugurated  by  the  injury,  and  impelled  by  the  same  force  that  carries  the 
normal  nutritive  supply  to  the  tissues,  only  somewhat  exaggerated,  continues 
to  relieve  itself  by  exudation,  until  the  necessity  for  the  increased  nutritive 
supply  ceases.  This  constant  supply  of  nutritive  material  for  the  growing 
granulation-cells  is  in  excess  of  the  demand.  After  percolating  through  the 
mass  of  granulation  tissue,  the  excess  of  liquid  exudation  reaches  the  granu- 
lating surface,  carrying  out  with  it  a  certain  proportion  of  the  leucocytes 
amongst  which  it  has  passed,  which  seem  also  to  be  in  excess  of  the  demand, 
and  thus,  finally,  makes  its  appearance  upon  the  granulating  surface,  as  pus. 
A  simple  experiment  shows  that  this  is  not  entirely  theory,  but,  in  some  de- 
gree, at  least,  demonstrable  fact.  If  the  surface  of  a  granulating  sore  be  care- 
fully dried  off  by  a  mop  of  absorbent  gotton,  and  then  subjected  to  the  action 
of  an  irritant,  that  is,  if  a  little  common  salt  be  sprinkled  upon  it,  or  a  hot  cau- 
tery iron  be  brought  almost  in  contact  with  it,  myriads  of  minute  drops  will 
be  seen  to  exude,  like  sweat,  from  the  previously  dried  surface.  jSTow,  if  a 
drop  of  this  fluid  be  placed  under  a  microscope,  it  will  be  found  to  contain 
leucocytes  in  numbers  ;  in  fact,  it  is  pus.1 

Under  all  the  various  circumstances,  therefore,  in  which  pus  is  formed  in 
the  body,  in  all  localities — whether  on  the  surface  of  mucous  or  serous  mem- 
branes, or  in  the  depths  of  the  tissues — these,  as  in  a  granulating  wound, 
would  seem  to  be  the  factors  which  contribute  to  its  formation :  liquid  exuda- 
tion from  capillary  vessels,  and  leucocytes.  A  surface  of  granulation  tissue  is, 
by  no  means,  the  only  source  of  pus ;  it  may  form,  under  certain  conditions, 
in  any  part  of  the  body.  It  is  meant  by  this  statement,  that  no  previously 
formed  granulating  surface  or  so-called  "pyogenic  membrane"  is  necessary  for 
the  formation  of  pus — a  doctrine  which  was  formerly  in  vogue. 

The  first  phenomenon  that  attends  pus  production  is  liquid  exudation ;  the 
next,  cell  germination.  It  may  be  understood,  now,  why  Robin  designates 
pus  as  an  "accidental  secretion;"  and  why  Billroth  insists  upon  calling  it 
"liquid  neoplasm."  On  the  other  hand,  it  is  to  be  kept  in  mind  that  granu- 
lations may  form,  grow,  and  develop  into  connective  or  cicatricial  tissue — as 
in  primary  union,  or  between  the  ends  of  subcutaneously  divided  tendons — ■ 
without  the  formation  of  a  drop  of  pus.  Its  presence  is  not,  therefore,  neces- 
sary for  the  accomplishment  of  the  process  of  repair  of  injury,  which  is  the 
main  purpose  of  inflammation. 

To  comprehend  the  sources  of  pus,  as  well  as  the  causes  and  modes  of  its 
formation,  it  is  desirable  to  examine  a  little  more  closely  the  phenomena  which 
attend  its  production  elsewhere  than  in  external  wounds:  in  abscess,  for  ex- 
ample, and  on  serous  and  mucous  membranes.  The  subject  of  abscess  will  be 
treated  formally  in  another  article  ;  it  is  referred  to  here  in  order  to  illustrate 
the  nature  and  mode  of  formation  of  pus  as  one  of  the  best  known  products 
of  inflammation,  and  to  enable  us  to  discuss  more  intelligently  the  question 
as  to  its  uses. 

An  abscess  is  a  collection  of  pus  in  the  substance  of  the  tissues.  An  acute 
abscess  affords  an  excellent  example  of  a  local  inflammation,  presenting  all  the 
cardinal  symptoms  and  features  of  this  condition,  and  usually  "terminating," 
to  employ  the  classical  expression,  in  suppuration.  Why,  and  how,  is  pus 
formed  in  the  substance  of  the  tissues,  are  the  questions  which  concern  us. 
Judging  from  clinical  observation,  the  reason  why  an  abscess  forms  is  to  get 
rid  of,  or  throw  off,  a  dead  or  altered  portion  of  tissue,  or  some  foreign  sub- 
stance, which  has  proved  noxious  or  irritating  to  the  organism.  Its  purpose, 
in  other  words,  seems  to  be  eliminatory.     ^VVe  have  already  remarked  that 

1  Cornil  and  Ranvier.  ut  supra. 


118  INFLAMMATION. 

pus  from  the  vicinity  of  diseased  bone  is  liable  to  contain  gritty  particles  of 
bone-earth.  The  core  of  an  ordinary  boil,  which  is  an  example  of  an  acute 
abscess,  consists  of  a  little  mass  of  filaments  of  yellow  elastic  tissue,  the  re- 
mains of  a  portion  of  connective  substance  which  for  some  cause  has  died  and 
become  liquefied — all  but  the  more  indestructible  yellow  elastic  element.  This, 
acting  as  a  foreign  body,  like  a  splinter,  has  proved  a  local  irritant,  and  caused 
festering,  or  pus  formation,  apparently  to  secure  its  escape  by  being  floated 
out  when,  in  its  natural  course,  the  contents  of  the  abscess  are  discharged.  - 
After  the  escape  of  its  core,  the  boil  promptly  gets  well.  The  little  flocculent 
curdy  masses  often  seen  escaping  from  abscesses  with  the  pus,  especially  from 
those  of  scrofulous  or  tuberculous  subjects,  where  the  general  condition  of  the 
patient  is  poor,  and  the  pus,  consequently,  thin  and  watery,  are  either  little 
aggregations  of  pus-cells,  or  altered  tissue — sometimes  tubercular  matter — 
little  cores,  in  short,  as  of  boils.  The  little  abscess,  or  pustule,  that  forms  in 
the  substance  of  the  skin  in  smallpox,  has  for  its  purpose  the  elimination  of 
the  disk-like  slough  of  true  skin  which  has  been  killed  by  the  variolous  poison 
in  its  effort  to  escape  through  the  emunctories  of  the  integument.  The  de- 
pression or  "  pit"  that  follows  marks  the  loss  of  substance. 

The  circumstance  of  textural  death,  or  of  change  in  chemical  or  vital 
qualities  under  the  multifarious  unfavorable  conditions  which  affect  the  blood 
and  nervous  centres,  so  as  to  disturb  the  equable  interchange  of  material 
which  belongs  to  normal  nutrition,  would  seem  to  be  a  fertile  cause  of  ab- 
scess. The  influence  of  disturbed  innervation  as  a  cause  of  abscess  is  exem- 
plified in  the  occurrence  of  stye  from  fatigue  of  the  eyes,  and  in  the  pustules 
of  acne,  symptomatic  of  sexual  abnormity,  which  disappear  after  marriage. 

As  to  the  mode  in  which  pus  formation  takes  place  in  the  substance  of  the 
tissues,  as  in  the  occurrence  of  an  abscess,  it  is  as  follows:  (1)  The  exciting 
cause,  whether  textural  injury  from  traumatism,  or  textural  degeneration  from 
local  disturbance  of  nutrition  begetting  a  source  of  irritation,  provokes  an 
afflux  of  blood  to  the  centre  of  excitement.  (2)  The  distended  capillaries 
give  forth  liquid  exudation,  which  coagulates,  at  the  centre  of  excitement, 
into  plastic  lymph,  distending  the  meshes  of  the  immediately  surrounding 
tissues  with  a  more  serous  fluid.  (3)  In  the  plastic  lymph  cell,  proliferation 
begins,  and  goes  on  to  the  formation  of  leucocytes,  which,  not  being  favorably 
situated  for  growth  and  development  into  tissue,  accumulate  as  pus.  The 
pus,  as  it  collects,  forms  a  cavity  for  itself,  as  we  shall  see  shortly,  and  the 
result  is  an  abscess.  These  phenomena  occur,  most  generally,  in  moderately 
rapid  succession,  and  are  attended  by  pain,  heat,  swelling,  and  redness — the 
latter  not  always  showing  itself  upon  the  surface  ;  evidences  of  constitutional 
disturbance  may  also  be  present,  most  frequently  in  the  shape  of  fever. 

With  these  attendant  symptoms  the  abscess  is  acute;  but,  as  in  cold  abscess, 
they  may  all  lie  absent,  with  the  exception  of  the  symptom  of  swelling,  which 
is  caused  by  the  accumulation  of  pus.  The  formation  of  a  cold  abscess  in 
many  cases  resembles  more  the  growth  of  a  tumor  than  a  result  of  inflamma- 
tion ;  nevertheless  the  mechanism  of  the  pus  formation  is  identical  with  that 
ab'cady  described,  only  the  phenomena  succeed  each  other  more  slowly. 
Th  i is,  in  a  psoas  or  lumbar  abscess,  some  local  degeneration  of  bony  or  white 
fibrous  tissue  may  serve  as  its  starting  point,  and,  as  in  the  former  instance, 
afflux  of  blood  is  provoked,  and  the  result  is  exudation  and  cell  germination. 
These  arc,  in  fact,  the  essential  and  peculiar  changes  which  constitute  inflam- 
mation; and  they  are  more  constant  than  the  cardinal  symptoms  they  occa- 
sion,  on  which  we  mainly  rely  for  its  diagnosis.  It  is  profitable  to  notice 
how  closely  the  pathological  changes  which  constitute  inflammation  approach, 
in   some  of  their  phases,  to  those  which  attend  the  growth  of  tumors;  and 


DESTRUCTIVE    INFLAMMATION PUS    FORMATION.  119 

how  both  of  these  series  of  changes  are  only  modifications  of  the  normal 
nutritive  process  as  seen  in  embryonic  growth  development. 

The  formation  of  pus  on  the  surface  of  a  serous  or  mucous  membrane,  as 
in  empyema,  or  urethritis,  is  attended  by  a  less  serious  vital  effort  than  its 
formation  in  a  wound,  or  in  an  abscess;  for  leucocytes,  it  must  be  remembered, 
already  exist  as  a  part  of  the  secretion  of  these  membranes  in  a  state  of 
health,  and  the  conversion  of  these  seeretions  into  pus  involves  little  more 
than  increased  activity  in  cell  germination.  The  exudation  constantly  taking 
place  from  the  network  of  capillaries  which  underlies  every  serous  and  rau- 
cous membrane,  furnishes  nourishment  for  the  epithelium  which  is  being  con- 
stantly renewed  on  their  free  surfaces.  ISTow,  if  the  equilibrium  of  health  be 
disturbed,  say  in  consequence  of  prolonged  chilling,  as  in  pleurisy,  or  through 
the  contact  of  a  poison,  as  in  gonorrhoea,  the  injury  thus  offered  creates  a 
fluxion  of  blood  to  the  capillaries  of  the  membrane,  and  a  consequent  incite- 
ment to  an  increase  of  cell  proliferation.  The  result  is  increased  discharge 
from  the  surface  of  the  membrane,  carrying  off  the  excess  of  cell  production  ; 
in  other  words,  a  discharge  of  pus.  If  young  epithelial  cells  are  identical 
with  leucocytes,  the  induction  of  suppuration  from  a  membrane  involves 
nothing  more  than  an  increase  of  local  nutritive  activity.  If  they  are  differ- 
ent, and  this  question  cannot  be  properly  discussed  here,  then  exfoliation  of 
epithelium  precedes  pus  formation,  as  asserted  by  Weigert1  concerning  fibri- 
nous exudation  from  mucous  surfaces,  which,  he  asserts,  is  only  possible  after 
the  epithelium  has  exfoliated. 

Suppuration  from  membranes  is  attended  usually,  but  not  always,  by  pain, 
heat,  increased  redness,  and  tumefaction  of  the  inflamed  surface  from  exuda- 
tion into  the  meshes  of  the  underlying  connective  tissue.  A  return  to  a  state 
of  health  is  marked  by  a  diminished  fluxion  of  blood  to  the  part,  and  conse- 
quent diminution  in  cell  production.  The  cells  resume  their  normal  tendency 
to  develop  into  epithelium;  the  pus,  just  in  the  same  proportion,  becomes 
thin  and  watery;  and  finally,  as  soon  as  the  normal  conditions  are  completely 
restored,  it  ceases.  Notice  that  an  application  of  dilute  ammonia,  a  chemical 
irritant,  would  give  rise  to  a  similar  succession  of  phenomena.  In  the  ex- 
periments of  Cornil  and  Ranvier,  a  solution  of  nitrate  of  silver  thrown  into 
the  peritoneal  cavity  of  the  rat,  was  followed  by  exfoliation  of  epithelium 
and  proliferation  of  leucocytes.  On  serous  membranes,  however,  except 
where  blood  poisoning  is  present,  or  the  injury  is  peculiar  and  sustained — as 
in  intestinal  perforation — increased  activity  in  cell  germination  tends  to  prompt 
tissue  formation,  resulting  in  adhesion  and  the  formation  of  false  membranes, 
and  not  to  pus  production.  We  may  observe  that  the  analogy  between  the 
occurrence  of  a  slow  and  insidious  purulent  collection  filling  the  cavity  of  a 
pleura,  and  the  equally  deliberate  formation  of  a  cold  abscess  in  the  loins,  is 
very  obvious ;  and  that  both  of  these  conditions  are  phases  of  inflammation. 
The  causes  which  determine  the  difference  between  the  manifestations  of  the 
inflammatory  condition  which  we  call  acute,  and  the  chronic  changes  of  which 
these  slow  collections  of  pus  are  examples,  are  not  clearly  made  out. 

Phenomena  attending  Pus  Formation  in  the  Tissues. — We  are  now  in  a 
position  to  take  cognizance  of  the  phenomena  which  succeed  the  formation 
of  pus  in  the  substance  of  the  tissues,  and  to  estimate  the  propriety  of  calling 
them  destructive.  After  this  we  shall  be  better  able  to  form  an  opinion  as 
to  the  uses  of  pus. 

When  pus  is  developed  in  the  substance  of  the  tissues  in  the  maimer  just  de- 

1  Ut  supra. 


120  INFLAMMATION. 

scribed,  these  latter  suffer  both  from  its  presence,  and  from  its  pressure ;  muscu- 
lar fibres  are  broken  down  ;  those  of  connective  tissue  give  way  or  are  pushed 
aside  ;  capillaries  and  nerves  are  first  put  upon  the  stretch,  and  then  ruptured. 
The  stretching  of  nervous  filaments  explains  the  sensation  of  aching  that 
belongs  to  acute  abscesses  when  forming,  and  their  rupture,  the  sharper 
sudden  darting  pains  that  occur  at  intervals.  In  this  manner,  by  steadily 
encroaching  upon  neighboring  parts,  pus  forms  a  cavity  for  itself.  The  forces 
by  which  this  end  is  accomplished  are  (1)  the  exaggerated  afflux  of  blood  to 
the  part,  indicated  by  the  pulsatile  character  of  the  pain,  and  evidently  de- 
rived directly  from  the  heart's  impulse ;  and  (2)  the  irrepressible  tendency  to 
cell-germination  provoked  by  the  exudation  which  is  being  constantly 
sweated  out  through  the  walls  of  the  distended  capillaries.  And  here  it  is 
again  worthy  of  notice  how  close  a  resemblance  exists  between  the  mode  in 
which  an  abscess  makes  a  place  amongst  the  tissues  for  its  growing  bulk, 
and  that  followed  by  a  round-celled  sarcomatous  tumor ;  a  resemblance  as 
close  as  that  which  is  recognizable  between  the  leucocytes  of  the  growing 
abscess  and  the  cells  of  the  sarcoma,  or  between  the  fluctuation  of  the  abscess 
and  the  feel,  which  so  closely  resembles  fluctuation,  of  a  soft  cancerous  tumor. 
But  pus,  it  is  to  be  observed,  may  form  where  there  are  no  capillaries,  in 
the  so-called  non-vascular  tissues,  as  between  the  layers  of  the  epidermis,  or 
in  the  substance  of  the  cornea,  or  of  cartilage.  In  regard  to  the  minute 
changes  which  occur  in  these  localities,  histologists  are  not  as  yet  entirely 
agreed.  It  may  be  stated  in  general  terms  that,  when  affected  by  inflamma- 
tion, the  non-vascular  tissue  tends  to  revert  for  the  time  to  its  embryonic 
condition.  Clinically  there  is  evidence,  as  regards  cartilage,  that,  in  wounds 
attended  by  loss  of  substance,  the  loss  is  substituted  by  connective  tissue, 
often  without  suppuration.  One  of  the  best  examples  of  this  result  is  the 
fibrous  anchylosis  that  follows  the  destruction  of  articular  cartilages.  They 
arc  replaced  in  many  cases  by  connective  tissue,  binding  together  the  ends  of 
the  bones,  and  at  the  same  time  preserving  a  limited  degree  of  motion — con- 
verting, in  short,  a  diarthrodial  into  a  synarthrodia!  articulation. 


Ulceration. 

The  phenomena  which  follow  the  formation  of  a  cavity  in  the  tissues  by 
a  collection  of  pus,  are  better  considered  now,  for  they  still  further  illustrate 
the  nature  of  this  typical  inflammatory  process.  Suppuration  occurring 
beneath  the  surface  may  culminate  in  several  ways,  but  the  most  common 
result,  certainly  of  an  acute  abscess,  is  for  the  cavity,  as  it  enlarges,  to  approach 
the  external  surface  of  the  body,  or  that  of  one  of  its  hollow  viscera — simply 
because  there  is  the  least  resistance  in  these  directions;  then  by  its  steadily 
increasing  pressure  to  cause,  first,  distension  and  stretching,  and,  in  the  next 
place,  ulceration,  of  the  tissues  subjected  to  its  action;  and,  finally,  for  the 
contents  of  the  abscess  to  be  discharged  through  the  opening  thus  effected 
by  the  ulcerative  process.  In  common  language  the  abscess  forms, .and  then 
bursts.  This  may  be  regarded  as  the  natural  termination  of  an  abscess;  and 
it  is  frequently  imitated  by  art.  The  phenomenon  of  ulceration,  by  which 
the  spontaneous  discharge  of  an  abscess  is  accomplished,  has  been  commonly 
described  as  one  of  the  "terminations"  of  inflammation,  because  it  apparently 
brings  this  usually  painful  process  to  an  end.  After  its  contents  have  been 
thus  evacuated,  all  the  symptoms  of  the  abscess  arc  strikingly  relieved,  and, 
;i  :i  rule,  it  gets  well  forthwith.  It  is  proper,  therefore,  to  notice  more  par- 
ticularly in  what  the  process  of  ulceration  consists. 

A-   an   abscess   increases   in  size,  a  certain  amount  of  redness  makes  its 


GANGRENE.  121 

appearance  upon  the  surface  which  it  is  approaching.  This  surface  redness 
is  usually  preceded  by  more  or  less  oedema  of  the  subcutaneous  tissue,  which 
is  explained  by  the  projection  of  the  peripheral  zone  of  serous  exudation 
surrounding  the  central  collection  of  pus.  The  advancing  tumor  next  pre- 
sents, at  the  centre  of  the  surface  redness,  a  more  prominent  and  bulging 
point,  where  the  color  of  the  skin  becomes  purplish  or  livid.  The  skin  is 
evidently  also  growing  thinner,  for  the  yellow  tint  of  the  pus  soon  becomes 
recognizable  through  it.  In  this  stage  an  abscess  is  said  to  be  pointing. 
Shortly  the  thinned  integument  gives  way,  and  the  pus  exudes  through  the 
opening.  The  cause  of  this  behavior  of  the  skin  is  simply  that  the  blood- 
vessels'by  which  its  nutritive  supply  is  conveyed  from  beneath,  have  been 
stretched  and  obstructed  by  the  pressure  of  the  enlarging  abscess,  or  have 
been  actually  ruptured  by  extreme  stretching,  so  that  the  area  of  integument 
thus  deprived  of  its  blood-supply  slowly  dies.  It  dies  by  minute  particles, 
or  molecules,  piecemeal ;  and  the  dead  material  is  added  to  the  contents  of 
the  abscess. 

Under  all  possible  circumstances,  this  molecular  death  is  the  essential  feature 
of  the  process  which  we  call  ulceration ;  and  its  immediate  cause  is  defect  in 
the  blood-supply.  It  is,  therefore,  a  passive,  not  an  active,  process,  brought 
about  by  agencies  external  to  the  parts  that  die.  It  is  probable  that  insuffi- 
cient supply  of  nervous  influence  aggravates  the  effect  of  the  vascular  defi- 
ciency ;  and,  in  some  cases,  a  bad  quality  of  the  blood,  or  the  blighting  effect 
of  a  virus  present  in  it,  may,  with  slight  additional  cause,  start  and  keep  up 
the  ulcerative  process,  as  in  some  phases  of  syphilis  and  phagedena.  In  any 
case,  the  relation  of  ulceration  to  inflammation  is  not  necessarily  that  of  effect 
and  cause;  for,  although  the  two  conditions  are  very  commonly  associated, 
and  the  same  causes  are  competent  to  excite  either  or  both  of  them  simulta- 
neously, nevertheless  ulceration  may  take  place  without  inflammation,  as 
exemplified  in  the  destruction  caused  by  the  slow  and  gradual  pressure  of  an 
aortic  aneurism  upon  the  sternum  or  vertebral  bodies.  Pathologically, 
ulceration  is  more  nearly  allied  to  atrophy,  and  the  retrogres^ve  changes 
which  follow  insufficient  nutrition ;  and,  whenever  the  process  takes  jflace,  it 
may  be  traced  to  one  or  more  of  the  causes  already  detailed,  without  neces- 
sarily including  inflammation.  .  The  relations  between  inflammation  and 
ulceration  resemble  in  many  points  the  relations  between  inflammation  and 
gangrene ;  they  are  incidental,  rather  than  causative.  They  have  been  in- 
cluded in  the  series  of  changes  following  injury,  with  a  somewhat  loose 
estimate  of  their  significance,  and  of  their  relations  to  inflammation  ;  but 
they  form  no  essential  features  of  the  inflammatory  condition. 


Gangrene. 

It  has  been  usual  with  surgical  writers  to  speak  of  gangrene  also  as  one 
of  the  "  terminations"  of  inflammation.  Tbe  sameness  as  to  immediate 
causes  renders  the  conclusions  reached  concerning  ulceration  applicable  also 
to  gangrene,  and  justifies  the  consideration  of  gangrene  in  its  relations  to 
inflammation  more  fully  in  this  connection. 

The  term  gangrene  is  applied  to  death  of  living  tissues  in  visible  masses  ; 
the  term  ulceration,  to  disintegration  of  tissue  by  the  death,  in  detail,  of  in- 
visible  molecules  ;  and  the  immediate  cause  of  the  local  death  in  either  case  is 
deprivation  of  an  adequate  supply  of  nutritive  material,  without  necessarily 
including  the  idea  of  inflammation. 

The  series  of  changes  following  injury,  which  are  correctly  regarded  as  con- 
stituting inflammation,  do  not  include  immediate  death  of  the  injured  part. 


122  INFLAMMATION. 

But  local  death  when  it  follows  an  injury  after  ever  so  short  an  interval,  even 
when  the  series  of  changes  has  been  very  imperfectly  inaugurated — perhaps 
not  even  begun — is  usually  credited  to  inflammation ;  whereas  it  should  be, 
probably  more  correctly,  ascribed  to  the  injury.  There  are  cases  occurring 
constantly  in  which  tissues  are  half  killed,  as,  for  example,  in  a  crushed  limb, 
and  are  unable  to  take  part  in  the  increased  nutritive  action  necessitated  by 
the  reparative  effort,  even  to  the  extent  of  separating  dead  from  living  parts. 
In  the  stasis  that  follows  the  first  afflux  of  blood,  these  tissues  perish,  through 
lack  of  vital  power  in  their  vessels  to  carry  on  the  circulation.  This  lack  of 
power,  through  injury,  may  manifest  itself  at  any  stage  of  the  constructive  pro- 
cess ;  and,  when  it  becomes  manifest,  sloughing  and  gangrene  take  place.  In 
this  sense  inflammation  may  be  said  to  terminate  in  gangrene.  But  it  would 
convey  a  more  correct  idea  of  the  pathological  condition  to  say  of  such  a  result 
that  the  injury  is  too  severe  to  be  remedied  by  the  limited  power  of  repair 
with  which  the  human  organism  is  endowed.  We  may  conclude  from  these 
considerations  that  neither  ulceration,  nor  gangrene,  can  be  properly  styled  a 
'"termination"  of  inflammation.  The  results  of  the  inflammatory  condition 
to  which  this  term  is  correctly  applicable,  will  be  enumerated  hereafter. 


The  Significance  of  Suppuration. 

Having  now  surveyed  the  different  forms  of  suppuration,  as  it  occurs  in 
wounds  in  the  process  of  healing  by  the  second  intention,  on  membranes,  and 
in  the  substance  of  the  tissues,  and  having  examined,  incidentally,  the  rela- 
tions of  ulceration  and  gangrene  to  inflammation,  we  are  in  a  position  to  form 
a  judgment  as  to  the  uses  of  pus,  and  the  general  significance  of  this  most 
characteristic  of  all  the  manifestations  of  the  inflammatory  condition.  Mean- 
while, however,  there  are  some  physical  qualities  of  pus,  connected  principally 
with  abscess  formation,  which  still  remain  to  be  noticed. 

Significance  of  Odors  from  Pus. — The  discharge  from  an  abscess,  espe- 
cially in  certain  localities  of  the  body,  is  liable  to  give  off  an  offensive  odor. 
This  is  due  to  contamination  by  fetid  gases  generated  in  the  vicinity  of  the 
abscess — pus,  like  other  substances  containing  fat,  becoming  readily  tainted. 
'J'li  i is,  the  power  by  which  gases  permeate  animal  membranes,  known  as  os- 
mosis, explains  the  fetor  of  the  pus  from  abscesses  forming  near  the  rectum, 
or,  in  fact,  in  the  neighborhood  of  any  part  of  the  alimentary  canal.  The 
badly  smelling  gases  generated  within  the  intestines  are  absorbed  by  the  pus 
formed  outside  of  it,  through  the  intervening  membranes.  This  is  true  of 
pns  forming  in  the  neighborhood  of  the  mouth,  tonsils,  pharynx,  and  oesoph- 
agus. A  peculiar  sour  smell  has  been  noticed  in  pus  from  the  vicinity  of  the 
small  intestine,  suggestive  of  the  earlier  stages  of  digestion.  There  is,  conse- 
quently, a  certain  diagnostic  value  in  the  odor  of  pus.  If  the  discharge  from 
an  abscess  of  the  neck  should  be  offensive,  it  may  be  safely  assumed  to  come 
from  a  source  ;(s  deep  as  the  pharynx. 

In  pus  which  is  retained,  and  at  the  same  time  mingled  with  the  secretions 
of  an  inflamed  mucous  membrane,as  in  that  which  occasionally  collects  in  the 
antrum  of  the  upper  jaw,  the  fetor  is  excessive.  In  ozsena,  or  where  dead 
bone  is  present,  or  ;i  foreign  body  wedged  in  the  nasal  cavities,  it  is  notori- 
ously offensive.  It  is  noticeable  that  in  each  of  these  cases  the  odor  is  pecu- 
liar, and  differs  from  all  others.  Substances  absorbed  into  the  blood  give 
their  odor  to  pus:  a  French  author  states  that  ulcers  of  the  leg  in  tanners, 
who  work  in  badly  smelling  hides,  a  re  "remarkable  for  their  extreme  fetor; 
and  the  odor  of  the  dissecting  rooms  has  been  recognized  in  the  pus  of  an 


THE   SIGNIFICANCE   OF   SUPPURATION.  123 

abscess  following  a  dissecting  wound.  The  pus  from  buboes  of  the  plague  is 
described  as  smelling  horribly,  and  that  from  the  pustules  of  smallpox  is 
peculiarly  disgusting. 

Under  other  circumstances,  when  pus  gives  off  a  fetid  odor,  if  this  is  not 
caused  by  the  admixture  of  dead  and  sloughy  material  foreign  to  its  own  sub- 
stance, it  is  the  result  of  actual  or  approaching  decomposition.  In  decompo- 
sition, the  sulphates  of  its  albumen  become  sulphurets,  and  free  sulphuretted 
hydrogen  is  extricated,  which  combines  with  the  ammonia  given  off  at  the 
same  time.  There  is  also  a  trace  of  phosphuretted  hydrogen  present  which 
contributes  to  the  odor.  Decomposition  of  pus  often  takes  place  around  a 
wound,  where  it  collects  and  dries  upon  the  surface  in  consequence  of  the  high 
temperature  of  the  body.  When  lotions  containing  lead  are  employed  under 
these  circumstances,  the  dressings  are  liable  to  be  colored  black  by  deposit  of 
the  sulphuret  of  lead. 

Poisonous  Qualities  of  Pus. — Opinions  have  varied  strangely  as  to  the 
possession  of  poisonous  qualities  by  pus.  Less  than  half  a  century  ago,  all 
the  fatal  surgical  fevers  were  habitually  ascribed  to  its  reabsorption  into  the 
organism  from  wounds.  After  the  old  theory  of  pyaemia  had  ceased  to  pre- 
vail, pus  was  regarded,  under  the  influence  of  the  chemico-vital  teachings  of 
Robin,  as  a  positively  innocent  substance.  More  recently  a  belief  has  become 
general  that  it  possesses  "  infective''  properties,  the  intimate  nature  of  which 
is  still  under  judgment.  Thus  we  may  say  that  normal  pus,  unless  some  virus 
or  poison  may  have  been  accidentally  introduced  into  it,  has  been  usually  re- 
garded as  a  bland,  innoxious,  unirritating  fluid.  But  experiments  upon  ani- 
mals, first  made  as  early  as  1849,  by  Sedillot,  and  more  lately  by  Billroth  and 
Weber,  Chauveau,  Senator,  and  others,  have  demonstrated  that  not  only  pus, 
but  other  products  of  healthy  inflammation,  when  introduced  into  the  organism, 
possess  the  power  of  exciting  inflammation  in  the  form  of  abscess  and  fever. 
In  the  experiments  of  Senator,  made  for  the  purpose  of  studying  fever,  per- 
fectly fresh  healthy  pus  was  injected  beneath  the  integuments  of  healthy  dogs, 
with  the  invariable  effect  of  producing  a  rise  of  temperature  within  an  hour 
or  two ;  but  a  large  proportion  of  the  dogs  thus  treated  died  in  a  few  days 
with  symptoms  of  septicaemia.  Chauveau  has  proved  that  the  fever-} >  re- 
ducing quality  of  pus  resides  in  its  solid  elements ;  for  injections  of  filtered 
liquor  puris  were  found  to  be  innocuous. 

These  facts,  and  many  others  of  similar  import  and  equal  interest,  are  to 
be  kept  under  advisement;  but  inferences  from  them,  as  applicable  to  the 
human  organism,  are  hardly  as  yet  justifiable  beyond  the  general  admission 
that,  in  a  certain  degree,  the  products  of  healthy  inflammation  possess  the 
itifcr-tive  quality. 

Where  a  wound,  or  an  ulcer,  is  partly  gangrenous,  or  phagedenic,  in  fact, 
up  to  the  time  when  a  complete  layer  of  health}'  granulation  lias  formed  upon 
its  surface,  its  pus  will  always  contain  more  or  less  dead  or  dissolving  tissue 
■ — detritus,  as  it  is  called.  The  yellowish-gray  flocculent  or  leathery  adherent 
material  which  cannot  be  washed  away  from  the  bottom  of  a  wound  or  ulcer, 
in  this  condition,  is  simply  dead  tissue  not  yet  cast  off,  because  granulations 
are  not  as  yet  completely  organized  beneath  it — the  organization  of  a  healthy 
layer  of  granulation  tissue  upon  the  living  surface  being  absolutely  requisite 
to  insure  the  safe  separation,  in  the  normal  order,  of  dead  from  living  parts. 

But  there  are  certain  circumstances  under  which  pus  does  acquire  poisonous 
properties  which  do  not  belong  to  it  per  se,  as  when  it  becomes,  accidentally, 
the  vehicle  of  a  virus,  as,  for  example,  the  virus  of  the  contagious  venereal 
ulcer  called  chancroid.  Under  these  circumstances  it  is  properly  denominated 
"virulent  pus."     Here  there  is  no  difference  whatever  demonstrable  by  the 


124  INFLAMMATION. 

microscope,  as  yet,  nor  by  the  strictest  chemical  analysis,  from  pus  of  ordi- 
nary quality.  The  virulence  of  pus  thus  contaminated  belongs  neither  to  its 
corpuscles,  nor  to  bacteria,  but  to  certain  unknown  substances  soluble  in  its 
serum,  analogous  to  those  which  exist  in  the  blood  in  syphilis,  in  the  nasal 
mucus  of  glanders,  or  in  the  saliva  of  hydrophobia.1 

Pus  Involves  Waste  of  Tissue. — It  has  been  rendered  sufficiently  obvious 
by  the  preceding  considerations  that  pus  production  involves  destruction  of 
tissue.  As  Strieker  asserts,  "  where  pus  is  formed  in  the  midst  of  the  tissues, 
the  tissues  must  be  disintegrated ;  it  is  the  tissue  itself  which  is  transformed 
into  pus-corpuscles."  In  addition,  adjacent  parts  are  damaged  by  interrup- 
tion of  their  function,  and  by  pressure;  and  local  death  is  produced  by  ulcera- 
tion. Pus  production,  in  the  case  of  wounds,  therefore,  involves  not  only 
delay  as  to  healing,  but  positive  destruction  and  waste  of  material  in  the 
consummation  of  the  healing  process ;  and  suppuration  is  properly  regarded 
as  a  symptom  of  the  destructive  phase  of  inflammation.  These  conclusions 
will  become  more  obvious  if  we  examine  a  little  more  closely  into  the  uses  of 
pus. 

Tses  of  Pus. — For  what  purpose  is  this  secretion  furnished  by  the  blood  at 
the  expense  of  the  tissues?  AVhat  are  really  its  uses?  These  questions  are 
readily  answered.  Many  and  different  uses  have  been  assigned  to  pus,  some  of 
which  are  entirely  fanciful.  James,  of  Exeter,  who  wrote  in  1832,  embodies 
the  general  sense,  at  that  date,  in  the  opinion  that  the  secretion  of  pus  is  a 
necessary  auxiliary  to  the  process  of  granulation,  for  "the  newly-formed  parts 
have  no  protection  to  defend  them  against  the  injurious  impressions  of  exter- 
nal agents;"  this  "appears  to  be  its  legitimate  use."  James  judiciously 
remarks,  concerning  pus,  that  "  if  we  can  sufficiently  protect  the  wound  from 
the  irritation  of  external  agents  it  will  heal  without  it ;"  referring  to  "  scab- 
bing," in  proof. 

At  an  earlier  date,  the  flow  of  pus  was  supposed  to  exercise  a  dcpiirative 
influence  both  upon  the  wound  and  upon  the  system  at  large.  It  was  thought 
to  cleanse  a  wound,  and  to  prepare  it  for  healing ;  and  means  were  commonly 
employed  to  promote  its  flow.  The  popular  mind  still  attaches  importance 
to  the  idea  that  suppuration  purges  the  body  of  something  injurious ;  and 
the  term  "corruption"  is  still  applied  to  pus,  and  a  certain  satisfaction  excited 
by  its  free  discharge.  Hence  one  of  the  sources  of  confidence  in  the  remedial 
power  of  setons  and  issues.  But  at  the  present  day,  the  conviction  has  gradu- 
ally come  to  prevail  that  these  uses  of  pus  are  imaginary.  The}7  certainly 
have  not  been  confirmed  by  the  increasing  accuracy  of  our  knowledge,  and 
the  opinion  of  Robin  is  now  generally  received.  This  writer  asserts,  broadly, 
that  "it  cannot  be  demonstrated  that  under  any  circumstances  suppuration 
does  good,  or  that  it  exerts  any  salutary  influence  by  depuration."2 

We  may  safely  regard  suppuration  as  simply  an  exuberant  overflow  of 
plastic  material.  The  leucocytes  which  are  washed  away  from  the  surface  of 
a  wound  arc  evidently  not  necessary  for  the  success  of  the  constructive  pro- 
They  are  in  excess  of  the  demand.  Their  fellows,  which  remain  behind, 
develop  into  tissue — tiny  subserve  a  useful  purpose;  but  those  which  are 
washed  away  as  pus-corpuscles  are  wasted — they  arc  abortions.  The  truth 
of  tliis  view  is  confirmed  by  what  happens  when  healthy  granulating  surfaces 
are  brought  in  contact  and  kept  carefully  in  apposition.  We  know  by  daily 
experience  that  they  unite  at  once  and  grow  together.  The  question  was 
asked  in  connection  with  this  mode  of  adhesion  of  granulations,  or  secondary 

•  Robin,  op.  cit.,  p.  414.  2  Op.  cit.,  p.  384. 


VAKIETIES   OF   PUS.  125 

adhesion — "  What,  in  this  event,  becomes  of  the  pus  ?"  The  answer  is  obvious : 
It  ceases  to  be  produced  the  moment  that  the  granulating  surfaces  are  success- 
fully brought  together.  The  immediate  demand  for  development  into  tissue, 
in  the  new  attitude  of  the  wound,  affords  ample  scope  for  both  the  force  and 
the  material  hitherto  wasted  ;  and  the  overflow,  as  pus,  is  at  an  end. 

It  is  by  this  same  mechanism  that  an  abscess  heals,  after  its  contents  have 
been  discharged.  The  walls  of  the  cavity,  lined  by  granulations  which  have 
formed  around  the  central  cause  of  irritation  by  which  the  abscess  was  pro- 
voked, tend  to  come  into  contact  as  its  contents  are  voided.  The  force  that 
brings  them  together  is  the  contractility  of  the  tissues  which  form  the  walls 
of  the  cavity.  If  this  tendency  is  intelligently  favored,  prompt  adhesion  fol- 
lows, and  the  discharge  of  pus  ceases.  Just  in  proportion  as  this  natural 
termination  of  the  constructive  inflammation  is  in  any  way  prevented,  the 
abscess  is  liable  to  result  in  a  sinus.  There  is  available  evidence  that  suppu- 
ration is  not  only  useless  and  wasteful,  as  shown  by  these  examples,  but  that 
it  is,  in  other  ways,  positively  injurious. 

And  yet  it  may  be  remarked  that,  as  far  as  the  eliminative  theory  as  to 
the  causes  of  abscess  formation  is  true,  pus  is  to  be  credited  as  an  adjuvant  in 
floating  out  foreign  substances  lodged  in  the  body,  and  noxious  materials  be- 
gotten within  it.  A  flow  of  pus  has  also,  a  certain  usefulness  in  floating  away 
foreign  and  dead  matter  from  a  foul  surface,  as,  for  example,  from  that  of  a 
contused  wound,  taking  a  helping  part  in  what  the  older  surgeons  called 
"  digestion"  of  the  wound.  To  this  extent,  therefore,  it  may  be  regarded  as 
as  eliminating  agent ;  and  in  the  lower  animals,  after  granulation  has  fairly 
begun,  pus  aids  in  forming  a  crust  by  which  cicatrization  is  favored.  Mean- 
while it  is  to  be  observed  that,  when  it  cannot  be  cut  short  by  promoting  the 
adhesion  of  granulating  surfaces — a  possibility  which  the  surgeon  should 
always  keep  in  view — the  normal  termination  of  suppuration  is  reached 
through  the  repressive  influence  of  cicatrization. 


Varieties  of  Pus. 

The  constitution  of  pus,  as  heretofore  remarked,  is  subject  to  constant 
variety,  not  only  in  different  individuals  and  forms  of  disease,  but  in  different 
conditions  of  the  same  individual,  and  in  different  localities  of  the  body. 
Under  the  influence  of  an  attack  of  indigestion,  for  example,  the  character 
of  the  pus  from  a  healthy  granulating  wound  will  give  evidence  of  tempo- 
rary change ;  and  after  a  chill,  as  of  pysemia,  it  usually  becomes  scanty,  thin, 
and  watery.  The  sudden  disappearance  of  the  purulent  discharge  from  a 
wound,  simultaneously  with  the  chill  by  which  grave  symptoms  were  ushered 
in,  naturally  suggested  to  the  surgeons  of  the  last  generation  that  the  serious 
change  in  the  patient's  condition  was  caused  by  "absorption  of  pus,"  and  the 
abscesses  in  the  internal  organs  which  followed,  seemed  to  lend  support  to 
this  idea.     But  these  facts  are  now  explained  differently. 

In  chronic  and  cold  abscesses  the  pus-corpuscles  have  often  a  pallid,  drop- 
sical appearance,  and  sometimes  their  nuclei  cannot  be  made  apparent  by 
adding  acetic  acid  ;  these  corpuscles  have  long  since  ceased  to  live,  and  are,  in 
fact,  beginning  to  undergo  solution.  The  serum  of  this  variety  of  pus  is, 
consequently,  rarely  transparent ;  it  is  generally  turbid.  With  these  water- 
soaked  pus-cells,  others  are  found  in  a  condition  of  fatty  infiltration.  In  pus 
from  abscess  of  the  female  breast,  during  lactation,  milk-globules  may  be 
found,  and  in  these,  as  well  as  in  abscesses  of  the  lymphatic  glands,  cells  of 
pavement  epithelium  from  the  ducts,  and  also  glandular  cells,  are  often  pre- 
sent.    If  we  knew  more  of  the  subtle  processes  of  organic  chemistry  carried 


126  INFLAMMATION. 

on  in  the  tissues  and  fluids  of  our  bodies,  we  should,  doubtless,  find  many 
products  derived  from  chemical  changes  in  these  unstable  albuminous  com- 
pounds, capable  of  acting  as  local  irritants,  and  of  causing  these  abscesses. 
Even  thinner  and  paler  than  the  pus  of  a  cold  abscess  is  that  from  cavities 
containing  dead  bone  left  behind  after  an  abscess  has  failed  to  eliminate  it ; 
here  we  find  sometimes  drops  of  oil  from  dissolving  marrow,  as  well  as  mi- 
nute granules  of  osseous  detritus  which  can  sometimes  be  felt  between  the 
finders.     Careful  scrutiny  may,  therefore,  in  any  case,  aid  in  diagnosis. 

Pus  from  varicose  and  indolent  ulcers,  from  ulcerated  epithelial  tumors, 
from  the  true  syphilitic  chancre,  and  also  from  phagedenic  ulcers,  is  thin, 
serous,  and  "  sanious,"  and  contains  more  or  less  detritus  of  tissue — qualities 
significant  of  the  absence  of  healthy  effort  in  the  way  of  repair.  The  type 
of  sanious  pus,  of  what  is  called  ichor,  is  found  in  the  discharge  from  an  open 
cancer ;  it  contains  much  already  dead,  or  liquefying,  cancer  tissue.  If,  on  the 
other  hand,  a  cancerous  tumor  be  removed,  freely  and  entirely,  and  the  wound 
left  open,  the  surrounding  healthy  tissues  will  shortly  eject  cream-like  pus, 
significant  of  active  cell  formation  and  rapid  repair.  Cancerous  ichor  is  often 
excessive  in  quantity  and  exhausting  to  the  strength  of  the  patient ;  it  is 
given  off  by  the  new  vessels  of  the  cancerous  growth  which  are  impotent  to 
furnish  true  exudation,  and  simply  exhaust  vital  force  in  the  effort. 


Substances  Mistaken  for  Pus. 

"We  have  said  that  pus  in  a  solid  form  has  been  mistaken  for  tubercle,  when 
developed  under  pressure  in  bone.  Solid  pus  occurs  also,  habitually,  in  other 
localities:  in  the  sulci  between  the  convolutions  of  the  surface  of  the  brain 
and  spinal  cord,  in  meningitis ;  on  the  iris,  where  it  can  often  be  seen  in  the 
form  of  little  rounded  masses,  in  iritis ;  in  the  cornea ;  and  in  other  tissues  of 
the  eye.  On  the  other  hand,  there  are  fluids  in  the  body,  and  even  solids, 
which  are  often  miscalled  pus,  in  which  the  microscope  fails  to  reveal  its 
characteristic  elements.  As  examples,  we  have  the  fluid  effused  in  peritonitis, 
or  pleurisy,  called  purulent,  but  often  nothing  more  than  the  serum  of  those 
cavities  with  a  few  leucocytes  in  suspension.  An  exaggerated  flow  of  mucus 
from  any  of  the  mucous  canals,  with  an  increase  in  number  of  the  leucocytes 
which  it  normally  contains,  often  forms  an  imitation  of  pus — as  in  the  fluid 
of  bronchorrhoea,  and  of  some  forms  of  gleet,  and  especially  in  rectal  mucus 
when  colored  yellow  by  bile.  The  fluid  found  in  the  pelves  of  the  kidneys 
after  death,  resembles  pus,  but  is  only  urine  holding  in  suspension  epithelium 
from  the  urinary  tubules.  A  similar  explanation  applies  to  the  fluid  which 
can  be  pressed  out  of  the  prostatic  ducts.  The  secretion  of  the  tonsils  collected 
in  its  crypts,  is  not  unfrequently  mistaken  for  pus,  and  ulceration  assumed 
to  be  present,  when  it  is  not.  Clots  of  blood  which  form  in  arteries  after 
ligature,  or  after  embolism,  are  liable  to  break  down  into  a  soft  yelldwish 
fluid  strongly  resembling,  pus  j1  and  a  similar  puriform  liquefaction  is  liable 
1o  take  place  in  other  tissues,  as  in  lymphatic  glands,  sometimes  in  the  tes- 
ticle, and,  more  rarely,  in  the  interior  of  fibrous  tumors. 


Injurious  Consequences  of  Suppuration. 

The  vital  effort  which  results  in  the  formation  of  pus  amongst  the  solid  tis- 
sues of  the  body,  just  as  in  wounds  and  on  membranous  surfaces,  only  in  a 

'  Virchovv,  Cellular  Pathology.     Translated  by  Chance.     London,  1860. 


PURULENT    INFILTRATION   WITH   CONNECTIVE-TISSUE   NECROSIS.  127 

greater  degree,  inevitably  involves  a  destruction  of  existing  tissue,  besides  the 
wasteful  overflow  of  anatomical  elements  which  we  have  already  recognized. 
Wherever  healing  has  followed  suppuration,  there  is  evidence,  in  the  depres- 
sion of  the  cicatrix,  and  in  the  general  shrinkage  in  volume  of  the  parts  in- 
volved, that  there  has  been  loss  as  to  bulk — certainly,  also,  as  to  quality — of 
pre-existing  tissue.  A  cicatricial  surface  never  contains  sweat-glands,  nor 
hair-bulbs,  and  only  after  a  good  deal  of  delay,  according  to  Paget,  the  yellow 
elastic  fibres.  "  But,"  it  may  be  asked,  "  is  not  the  healing  of  the  wound  to 
be  credited  to  the  suppuration  ?"  By  no  means.  A  moment's  reflection  will 
recall  the  fact  that  the  most  prompt  and  solid  healing  with  least  loss  of  sub- 
stance, is  accomplished  in  primary  union,  in  the  subcutaneous  consolidation 
of  a  divided  tendon,  and  in  that  of  a  simple  fracture,  where  there  is  no  pus 
formation  whatever;  in  short,  that  new  tissue  is  freely  generated  without 
its  aid. 

Again,  examples  are  occurring  constantly,  in  practice,  of  patients  wasting 
with  suppuration  who  are  benefited  by  cod-liver  oil ;  and  of  amputation  for 
injuries  of  limbs  in  which  repair  has  failed,  and  where  improvement  in  the 
patient's  condition  has  begun  at  once  after  the  removal  of  a  source  of  exhaust- 
ing and  impotent  suppuration.  Daily  experience  tells  us  that  hectic  fever  is 
coincident  with,  if  not  caused  by,  suppuration  from  surfaces  incapable  of  heal- 
ing. We  have  to  add,  also,  to  the  injurious  effects  resulting  from  pus  produc- 
tion, the  possibility  of  amyloid  degeneration  of  the  arteries  and  the  viscera ; 
for  modern  pathology  has  recognized  prolonged  suppuration  as  one  of  the 
most  common  causes  of  this  grave  and  obscure  affection.  The  conclusion, 
therefore,  seems  to  be  unavoidable  that  the  secretion  of  pus  is  not  only,  in  a 
general  way,  useless  and  wasteful,  but  that  it  is,  in  many  cases,  positively  in- 
jurious; while  the  benefit  to  be  derived  from  it  is  uncertain,  and  in  some 
degree,  hypothetical. 

It  is  desirable  that  the  surgeon  should  recognize  these  truths,  and  assume 
it  as  a  duty  not  only  to  favor  rapid  union  in  wounds,  and  a  prompt  cure  in 
abscess  and  sinus,  wherever  this  result  is  feasible,  but  under  all  circumstances 
to  avoid  suppuration  as  much  as  possible,  and  to  arrest  it  always  as  soon  as 
he  can,  keeping  in  mind  the  fact  that  the  formation  of  pus  involves  the  ex- 
penditure of  vital  force  just  as  much  as  the  construction  of  tissue. 

Purulent  Infiltration  with  Connective-Tissue  Xecrosis. 

Three  ways  have  been  thus  far  described  in  which  pus  formation  takes  place 
in  the  organism:  (1)  on  the  surface  of  wounds  healing  by  granulation;  (2)  on 
serous,  mucous,  and  tegumentary  surfaces ;  and  (3)  in  the  form  of  a  collection 
imbedded  in  the  tissues  and  bounded  by  well-defined  walls,  as  an  abscess. 
There  is  a  fourth  variety  in  which  pus  formation  is  not  unfrequently  encoun- 
tered, namely,  as  an  infiltration  into  the  substance  of  a  part — mostly  into  the 
meshes  of  the  connective  tissue,  or  into  the  cellular  interspaces  occupied  by 
this  substance— with  a  tendency  to  spread  or  travel,  and  showing  no  disposi- 
tion to  self-limitation  as  in  abscess.  From  abscess,  which  is  always  charac- 
terized by  limitary  walls,  this  mode  of  pus  formation  is  distinguished  as 
purulent  infiltration,  and  it  is  also  often  spoken  of  as  "diffused  inflammation" 

This^  obscure  term  was  first  applied  by  Duncan,  of  Edinburgh,1  to  the  pus 
formation  formerly  so  common  in  the  axilla,  and  deeply  amongst  the  muscles 
of  the  arm  and  thorax,  after  dissection  wounds,  and  after  venesection,  in  which 

1  Cases  of  Diffuse  Inflammation  of  the  Cellular  Texture,  with  the  Appearances  on  Dissection, 
and  Observations.  By  Andrew  Duncan,  Jun.,  M.D.,  etc.  Edinburgh  Medico-Chirurgical 
Transactions,  vol.  i.  p.  470,  1S24. 


128  INFLAMMATION. 

the  tendency  to  self-limitation  was  noticeably  absent.  It  has  since  been  ap- 
plied by  English  surgeons  to  the  diffuse  and  spreading  suppuration  attending 
erysipelas  when  this  disease  affects  the  parts  beneath  the  surface.  The  French 
surgeons  speak  of  this  variety  of  inflammation  as  diffused  phlegmon.  The 
relation  it  bears  to  erysipelas  has  always  been  vaguely  defined ;  but  our  ideas 
are  clearer  since  modern  surgical  pathology  has  recognized  that  each  of  these 
forms  of  spreading  inflammation,  as  well  as  simple  cutaneous  erysipelas,  has 
for  its  cause  a  peculiar  infective  poison  analogous  to  that  discovered  by  Koch, 
by  which  he  produced  spreading  gangrene  in  mice.  The  common  effect  of 
these  poisons,  in  man,  is  to  cause  more  or  less  rapid  death  of  the  connective 
tissue  when  brought  in  contact  with  its  meshes  by  the  lymphatics,  or  other- 
wise. The  effect  produced  by  putrid  or  altered  urine,  when  extravasated  into 
the  connective  tissue,  illustrates  the  liability  of  this  structure  to  die  promptly 
in  consequence  of  such  noxious  contact.  It  is  the  putrid  element  in  this  case 
that  kills,  for  experience  has  demonstrated  that  the  contact  of  healthy  urine 
with  the  tissues  does  not  necessarily  impair  their  vitality.1 

A  contused  wound  of  the  hand  in  a  mechanic,  in  which  prompt  healing  has 
been  prevented  by  neglect  or  exposure,  is  liable  to  become  complicated  by  a 
diffuse  swelling  of  the  forearm,  with  purulent  infiltration  of  its  muscular  in- 
terspaces. This  complication  has  been  described  as  "subfascial  inflammation ;" 
in  reality  it  is  a  connective-tissue  necrosis  from  poison  brought  by  the  lymph- 
atics from  the  festering  wound  of  the  hand.  Dr.  Weir  Mitchell,  in  his  study 
of  the  effects  of  the  venom  of  the  rattlesnake,  describes  in  detail  the  influence 
of  this  poison  upon  the  tissues  at  and  near  the  wound.  When  the  victim  sur- 
vives the  first  eifects  upon  the  nerve  centres,  the  suppuration  that  follows  a 
snake-bite  is  of  the  diffuse  variety — the  half-poisoned  tissues  in  the  neighbor- 
hood seeming,  for  a  time  at  least,  unequal  to  the  task  of  getting  up  a  barrier 
of  healthy  granulations  to  limit  its  advance  and  serve  as  a  basis  for  repair; 
and,  before  final  healing,  sloughy  masses  of  dead  tissue  are  always  thrown  off. 
This  latter  phenomenon  is  mentioned  by  Dr.  Duncan  in  those  of  his  cases 
of  "diffused  cellular  inflammation"  in  which  the  patients  survived;  and  it 
is  a  well-known  feature  in  phlegmonous  erysipelas,  and  "  subfascial  inflam- 
mation." 

In  a  word,  then,  the  pathology  of  the  present  day  does  not  clearly  recog- 
nize any  especial  significance  in  any  of  these  terms,  and  tends  to  substitute 
for  them  death  of  tissue  from  contact  of  a  poison,  and  pus  formation  for  the  pur- 
pose of  eliminating  dead  tissue.  The  effort  at  pus  formation  is  weak  and  dif- 
fuse, simply  because  the  influence  of  the  poisonous  contact  impairs  in  a 
greater  or  less  degree  the  vitality  of  the  neighboring  tissues,  and  weakens 
their  capacity  for  prompt  and  healthy  repair.  As  soon  as  the  poisonous 
influence  ceases,  more  vigorous  and  healthy  granulations  are  formed,  and  the 
production  of  new  connective  tissue  goes  on  as  in  ordinary  constructive 
inflammation. 

The  characteristic  symptoms  of  this  variety  of  inflammation  are  a  peculiar 
doughy,  boggy  feel,  attended  by  deep  soreness  on  pressure,  but  rarely  a  dis- 
tinct  sense  of  fluctuation,  with  a  variable  amount  of  surface  redness,  perhaps 
a  brawny  thickening  of  the  skin  over  the  atfected  part,  and  a  tendency  to 
surface  gangrene,  in  patches,  from  cutting  off  of  the  vascular  supply  of  the 
skin.  Tims,  one  of  the  best  remedies  of  the  surgeon  is  to  save  surface 
sloughing,  and  fever,  by  Liberal  incision  of  the  integument,  in  order  to 
facilitate  the  early  escape  of  deeper  sloughs.     In  these  incisions  he  recog- 

'  In  a  patient  shot  through  the  distended  bladder,  recovery  followed  without  any  sloughing. 
(Vati  Buren.  New  York  Medical  Journal,  May,  1865.)  Subcutaneous  injections  of  fresh  healthy 
uriue  made  experimentally  by  Keyes  in  man,  were  followed  by  no  irritation  or  trouble  whatever. 
(Van  Burcii  and  Keyes,  Diseases  of  the  Uenito-urinary  Organs,  p.  144.    New  York,  1874.) 


HECTIC   FEVER.  129 

nizes  a  soft-solid  condition  of  the  subcutaneous  layer,  the  meshes  of  which 
seem  distended  with  fluid  exudation  of  varying  consistence,  with  softer 
portions  of  evidently  dead  tissue  resembling  wet  tow  and  bathed  in  pus,  and 
sometimes  softened  and  dead  muscular  substance. 


Hectic  Fever. 

As  most  frequently  encountered  in  connection  with  the  waste  and  conse- 
quent vital  exhaustion  from  pus  production  attending  lesions  beyond  repair, 
Hectic  Fever  is  properly  treated  of  as  a  symptom  of  destructive  inflammation. 
It  is  a  persistent,  teasing,  low  form  of  continued  fever,  characterized  by 
morning  remission  and  nocturnal  exacerbation ;  manifesting  a  pretty  con- 
stant and  regular  succession  of  chill,  fever,  and  sweating,  in  the  course  of 
every  twenty-four  hours  ;  and  characterized  by  progressive  emaciation,  with 
a  tendency  to  a  fatal  termination  unless  its  cause  be  removed. 

The  immediate  or  exciting  cause  of  hectic,  like  that  of  the  other  surgical 
fevers,  is,  as  far  as  we  know,  the  absorption  into  the  blood  of  some  of  the 
fever-producing  products  of  inflammation,  by  small  quantities — instalments, 
as  it  were — day  by  day,  never  sufficient  to  raise  the  temperature  of  the  blood 
high  enough  to  produce  immediately  fatal  results,  but  keeping  up  a  steady 
persistent  drain  upon  the  system  in  the  way  of  combustion  of  the  tissues. 
As  to  its  remoter  causes,  hectic  is  neither  an  essential  nor  yet  an  eruptive 
fever;  it  is ^ universally  regarded  as  symptomatic,  and,  as  already  suggested, 
symptomatic  of  some  lesion  of  the  organism,  generally  attended  by  suppura- 
tion, with  which  the  reparative  powers  are  unable  to  cope.  Chronic  diseases 
of  the  larger  joints,  and  compound  fractures  with  ineffectual  drainage,  are 
common  examples  of  the  surgical  lesions  which  cause  hectic.  It  may  exist 
where  there  is  no  actual  suppuration,  but  such  instances  are  rare. 

The  occurrence  of  hectic  in  phthisis  is  regarded  as  an  indication  that  soft- 
ening of  tubercular  deposit  has  taken  place.  A  cold  abscess  may  have  been 
growing  for  many  months  without  any  evidence  of  fever ;  but  if  its  contents 
be  suddenly  discharged,  and  the  air  has  access  to  its  cavity,  a  chill  almost 
invariably  occurs  within  a  day  or  two,  followed  by  fever  and  sweating ;  and 
the  daily  repetition  of  these  phenomena  marks  the  inauguration  of  hectic. 
If  the  vomica  of  the  lungs,  under  exceptionally  favorable  circumstances, 
should  heal,  or  if  the  walls  of  the  abscess,  instead  of  sloughing  piecemeal, 
should  unexpectedly  granulate  and  adhere,  the  first  evidence  of  this  happy 
occurrence  in  either  case  would  be  cessation  of  the  hectic  fever.  A  case  has 
been  already  mentioned  in  which  the  amputation  of  a  thigh  for  chronic  joint 
disease  was  followed  by  immediate  and  marked  improvement ;  this  was  due 
to  the  cure  of  hectic  by  removal  of  its  cause.  One  of  the  very  common 
occasions  of  secondary  amputation  in  hospital  practice  is  irremediable  injury 
of  a  limb,  most  frequently  through  the  consequences  of  compound  fracture, 
for  the  purpose  of  preventing  death  by  hectic  fever. 

The  fatal  result  is  brought  about  surely  and  steadily  by  the  waste  of  vital 
resources  through  combustion  of  tissue  material  to  keep  up  the  fever  heat. 
Patients  with  hectic  often  consume  a  good  deal  of  nourishment,  but  it  seems 
to  do  them  but  little  good  ;  emaciation  goes  on  in  spite  of  the  beef  and  the 
porter  and  the  cod-liver  oil.  The  eyes  of  the  patient  become  more  deeply 
set,  the  ears  more  transparent,  and  the  outlines  of  the  skeleton  more  dis- 
tinctly visible.  So  in  the  dogs  who  were  the  subjects  of  Weber's  fever 
experiments  ;  the  animals  in  a  state  of  fever  who  were  fed  to  the  extent  of 
their  capacity,  lost  weight  more  rapidly  than  those  without  fever  who  were 
simply  deprived  of  all  food  and  dying  of  inanition.  The  slow  progress  of 
vol.  i. — 9 


130  INFLAMMATION. 

hectic  fever  towards  its  usually  fatal  termination,  is  explained  by  the  fact 
that  the  temperature  of  the  blood  is  not  sustained  at  a  high  figure ;  it  rarely 
exceeds  103.5°  Fahr.,  and  falls  two  or  three  degrees  in  the  morning  under  the 
influence  of  the  nocturnal  perspiration— sometimes  even  below  the  normal 
standard.  Before  midday,  the  chilly  period,  which  may  be  very  slight, 
comes  on,  and  is  followed  inevitably  during  the  remainder  of  the  day  by 
fever,  and  during  the  night  by  sweating,  often  profuse.  Sometimes  there  is 
a  double  movement,  with  chilliness  in  the  afternoon  as  well  as  in  the  morning. 

The  best  diagnostic  signs  of  hectic  from  typhoid  or  malarial  fevers,  are  the 
regularity  of  the  night-sweats  in  hectic,  and  the  fact  that  the  pulse  retains 
its  frequency  during  the  apyrexia,  even  in  the  morning  when  the  temperature 
is  down  to  the  natural  degree.  This  depression  of  temperature  in  the  morn- 
ing bears  a  certain  relation  to  the  profuseness  of  the  sweating  during  the  night, 
and  is  associated  with  feelings  of  weakness  and  depression. 

The  worst  signs  in  hectic  are  the  intensification  of  its  symptoms ;  increas- 
ing frequency  of  pulse ;  higher  fever  in  the  evening,  with  greater  depression 
towards  morning ;  more  exhausting  sweats  at  night,  with  the  occurrence  of 
diarrhoea,  and  aphtha?  in  the  mouth.  The  sweats  and  diarrhoea  are  called 
colliquative  in  consequence  of  the  rapid  emaciation  and  exhaustion  by  which 
they  are  accompanied. 


Chronic  Inflammation. 

Of  all  the  various  forms  which  the  inflammatory  process  is  liable  to  assume, 
the  most  common  is  that  known  as  chronic  inflammation,  in  which  the  condi- 
tion tends  to  persist  indefinitely,  for  the  main  reason  that  the  object  for  which 
the  increased  nutritive  effort  has  been  undertaken  has  proved  to  be  unattain- 
able. The  dominant  idea,  which  will  explain  most  of  the  phenomena  pecu- 
liar to  this  condition,  is  the  non-fulfilment  of  a  jnirjiose. 

In  chronic  inflammation,  all  the  cardinal  symptoms  may  be  present,  but  in 
a  limited  degree,  the  causes  on  which  they  depend  being  very  much  dimin- 
ished in  their  intensity;  fain  is  comparatively  slight — it  may  be  entirely 
absent,  or  intermittent,  or  possibly  represented  by  itching  ;  heat  is  generally 
recognizable,  but  is  not  a  prominent  symptom  ;  redness  is  represented  by  a 
dull  tint,  sometimes  livid,  in  consequence  of  passive  hyperemia  from  stretch- 
ing of  the  vessels  by  previous  over-distension  and  existing  diminished  activity 
of  the  circulation ;  swelling,  the  most  important  of  the  four,  takes  the  form 
of  induration,  because  the  exudation  has  had  time  to  become  organized  into 
tissue :  hence  the  hard  embankment  around  an  indolent  ulcer,  and  the  almost 
cartilaginous  hardness  surrounding  an  old  sinus — a  fistula  in  ano,  for  example. 

In  the  latter  affection,  which  affords  perhaps  the  best,  because  the  most 
familiar,  surgical  illustration  of  chronic  inflammation,  an  abscess  has  been 
prevented  from  healing  by  too  much  motion  in  its  immediate  neighborhood. 
Its  walls  have  shrunken,  but  have  failed  to  unite,  through  lack  of  sufficiently 
prolonged  quiet  contact;  a  limited  amount  of  inflammatory  exudation  is  still 
furnished,  a  portion  of  which  goes  to  build  up  the  sheathing  of  cartilaginous 
hardness  outside  of  the  cylindrical  tube  which  remains,  and  the  rest  of  which 
furnishes  the  scanty  supply  of  serous  pus  yielded  by  the  internal  walls  of  the 
sinus.  These  Avails  are  lined  by  what  remains  of  the  granulating  surface  of 
the  origi  nal  abscess.  The  granulations  are  now  scanty  in  number  and  irregular 
in  size  ;  most  of  tbe  surface  is  red  and  smooth,  and,  if  closely  examined,  will 
be  found,  to  the  naked  eye,  to  resemble  mucous  membrane.  In  fact,  this 
close  resemblance  of  the  internal  surface  of  an  old  sinus  to  a  membrane,  led 
to  the  impression,  so  long  prevalent,  that  there  was  an  especial  membrane 


\ 


CHRONIC   INFLAMMATION.  131 

whose  office  it  was  to  secrete  pus.  The  name  pyogenic,  or  "  pus-begetting," 
which  was  applied  to  this  supposed  membrane,  is  still  in  use  in  this  sense ; 
but  the  means  of  closer  scrutiny  now  at  our  command  have  demonstrated 
clearly  that  no  such  membrane  actually  exists.  The  surface  to  which  the 
name  was  applied  is  simply  granulation  tissue,  in  a  passive  condition  of  sus- 
pended development,  awaiting  its  opportunity  of  final  growth  into  tissue  of 
cicatrix. 

This  is  confirmed  by  what  follows  when  such  a  sinus  is  laid  open  by  the 
knife.  Under  these  circumstances,  the  stimulus  of  injury  starts  the  construc- 
tive effort  anew  ;  the  chronic  inflammation  is  replaced  by  a  renewed  afflux  of 
blood  ;  a  fresh  exudation  of  better  quality  is  furnished  ;  and  the  old  surface 
of  granulation  tissue  sprouts  afresh  in  the  effort  at  cicatrization. 

The  condition  known  as  induration  is  one  of  the  characteristic  features  of 
chronic  inflammation.  It  is  very  familiar  to  us  as  a  consequence  of  certain  in- 
flammations of  internal  organs,  as  in  consolidation  of  the  lungs,  and  cirrhosis 
of  the  liver  ;  and  it  occurs  constantly  in  surgical  affections,  notably  around 
joints  long  diseased.  Especially  does  induration  take  place  where  constructive, 
inflammation  has  been  prevented  from  attaining  its  object  in  the  healing  of 
a  breach  of  continuity.  The  nutritive  material,  brought  for  the  purpose  of 
aiding  repair,  remains  unused  in  the  form  of  new  tissue  growth,  more  or  less 
organized,  which  collects  around  the  capillary  vessels  furnishing  the  exuda- 
tion. It  is  new  tissue  formation  intended  for  repair,  but  diverted  from  its 
object. 

This  increase  in  the  numerical  elements  of  the  connective  substance  imme- 
diately surrounding  the  capillary  vessels,  constitutes,  in  the  term  first  em- 
ployed by  Virchow,  hyperplasia — a  redundant  tissue  formation  by  elements 
which  have  been  turned  aside  from  their  purpose.  The  use  of  this  term 
serves  to  distinguish  an  increase  in  bulk  caused  by  inflammatory  induration, 
from  hypertrophy,  which  is  a  purposive  overgrowth  of  an  organ  generally 
provoked  by  its  increased  use ;  the  habitually  increased  functional  activity 
soliciting  constantly  a  larger  supply  of  nutritive  material. 

It  is  proper  to  notice  that  the  new  tissue  growth  which  constitutes  inflam- 
matory induration,  is  less  perfectly  organized  than  the  more  normal  growth  of 
cicatricial  tissue ;  hence  induration  may  be  removed  by  absorption,  by  atrophy, 
or  by  retrogressive  changes,  such  as  fatty  degeneration.  Thus,  systematic 
pressure  will  cause  the  rapid  disappearance  of  the  embankment  of  induration 
surrounding  a  chronic  ulcer  of  the  leg. 

It  is  well  known  that  all  new  formations  are  less  enduring  in  quality  of 
organization  than  the  original  tissues  of  the  body.  Thus  cicatrices  are 
notoriously  liable  to  injury  by  pressure,  as  in  a  leg  stump  after  an  ampu- 
tation ;  and  under  the  influence  of  exhausting  diseases  they  may  even  re- 
ulcerate,  as^  in  scurvy.  But  the  substance  of  inflammatory  induration  ranks- 
still  lower  in  the  scale  of  textural  vitality ;  and  this  lack  of  quality  is  con- 
stantly taken  advantage  of  by  the  surgeon  in  treating  the  consequences  of 
inflammation.  In  laying  open  old  sinuses,  the  dense  gristly  character  of  the 
induration  surrounding  them  may  present  itself  as  a  discouraging  feature  as 
regards  immediate  cure ;  but,  if  the  operation  be  thoroughly~accomplishedr 
the  suspicious  hardness  of  the  "  lardaceous  tissue,"  as  the  French  have  called 
it,  rnelts  away  with  surprising  promptness,  and  a  soft  bed  of  healthy  granu- 
lation tissue  succeeds. 

In  a  mucous  membrane,  the  induration,  which  is  as  characteristic  of  its 
chronic  inflammations  as  suppuration  is  of  their  acute  stage,  is  effected  by 
exudative  infiltration  into  the  meshes  of  the  submucous  connective  tissue. 
In  serous  membranes,  similar  thickening  from  induration  occurs,  but  is  less 
common. 


132  INFLAMMATION. 


Catarrhal  Inflammations. 

The  group  of  inflammations  called  catarrhal,  constitutes  a  variety  presenting 
certain  well-marked  features.  They  occur  in  mucous  membranes  only,  and, 
as  the  term  catarrh  implies,  are  characterized  by  increased  discharge,  as 
a  cardinal  symptom.  Rarely  acute,  except  when  excited  directly  by  trau- 
matism, poisonous  contact,  or  the  influence  of  chilling,  the  catarrhal  inflam- 
mations belong,  therefore,  to  the  chronic  class,  and,  with  the  exceptions  just 
noted,  are  chronic  from  the  first,  both  as  regards  mildness  of  symptoms  and 
tendency  to  indefinite  continuance. 

Some  of  the  causes  of  chronic  catarrh  are  exposure  to  habitual  contact  of 
irritating  substances,  as,  in  the  case  of  the  air-passages,  to  dust,  to  very  cold 
or  very  warm  air,  or  to  sudden  alterations  of  temperature  ;  in  the  case  of  the 
urinary  passages,  to  concentrated  or  exceptionally  irritating  urine ;  in  the 
female  passages,  to  acrid  uterine  discharges,  aided  by  obstruction  to  circula- 
tion from  the  varying  volume  of  the  uterus.  Certain  constitutional  and 
meteorological  causes  contribute  strongly  to  the  production  of  chronic 
catarrhal  inflammation,  e.g.,  the  peculiar  irritability  of  membranes  that 
belongs  to  the  gouty  diathesis ;  the  relaxed  condition  and  slowness  to  take 
on  a  healthy  state  after  injury  that  occurs  so  constantly  in  the  scrofulous ; 
and  sudden  or  frequent  changes  of  temperature. 

The  discharge  in  catarrh  consists  of  an  increase  in  the  normal  secretion  of 
the  part  by  the  addition  of  more  or  less  inflammatory  exudation.  It  con- 
tains also  an  increased  number  of  cellular  elements,  besides  the  occasional 
mucous  corpuscles  and  exfoliating  epithelium  usually  present,  in  the  shape 
of  leucocytes  and  young  epithelium.  When  the  proportion  of  leucocytes  is 
large,  the  discharge  puts  on  the  aspect  of  pus.  Under  these  circumstances 
the  grade  of  the  inflammation  more  nearly  approaches  the  acute  form ; 
exfoliation  of  epithelium  is  more  complete ;  and  the  exudation  from  the 
sub-epithelial  surfaces  partakes  more  of  the  character  of  true  inflammatory 
effusion.  This  exudation  tends  also  to  infiltrate  the  sub-epithelial  connective 
layer  surrounding  the  capillaries,  with  leucocytes,  and  thickening  of  the 
membrane  follows  as  a  consequence  of  their  germination  and  development. 

As  to  the  changes  which  take  place  in  the  epithelium  lining  the  follicles 
of  an  inflamed  mucous  membrane,  histologists  are  not  fully  agreed.  These 
little  mucous  glands  often  enlarge  and  become  more  prominent.  As  in 
follicular  pharyngitis,  their  secretion  fails  to  lubricate  the  gullet,  and  there 
are  dryness  and  pain ;  or,  as  in  urethritis,  a  little  submucous  abscess  may 
form  ;  or  there  may  be  ulceration  from  obstruction  of  the  follicular  outlet ; 
but  the  latter  is  rare  except  in  tuberculosis  or  epithelioma,  or  where  there  is 
coexisting  disease  of  periosteum  of  bone,  as  in  syphilitic  ozsena. 

The  nature  of  the  discharge  in  chronic  catarrh  is  liable,  therefore,  to  vary 
with  the  grade  of  the  inflammation,  the  constitution  of  the  individual,  and 
the  locality  in  which  it  is  developed,  as  well  as  with  the  nature  of  its  excit- 
ing cause.  In  regard  to  the  latter,  it  is  of  the  first  importance  to  form  a 
correct  opinion.  This  is  to  be  done  by  careful  and  thorough  inspection  of 
the  affected  surface,  as  far  as  possible,  and  by  close  scrutiny  of  the  discharge  as 
to  its  physical  character,  and  especially  its  anatomical  elements.  It  is  not 
rare  for  u  chronic  discharge  of  the  ear  to  be  kept  up  by  the  presence  of  a 
foreign  body;  and  this  is  also  occasionally  true  of  nasal  catarrh.  The  odor 
of  the  discharge  in  the  ozsena  or  scrofulous  nasal  catarrh  of  early  life,  is  so 
peculiar  as  to  be  diagnostic ;  its  vulgar  name  in  France  is  taken  from  that 
of  the  bedbug.  The  odor  exhaled  by  the  nasal  secretions  of  syphilis,  even 
where  no  dead  bone  is  present,  is  often  very  characteristic.     As  already 


INFLAMMATION   IN   THE   SCROFULOUS.  133 

mentioned,  the  chemical  decomposition  of  pus,  in  catarrh  of  the  bladder,  by 
the  reaction  of  the  ammonia  of  the  retained  urine,  produces  a  gelatinous 
mass  that  usually  passes  for  mucus,  and  its  resemblance  to  the  nasal  mucus 
in  an  ordinary  cold  undoubtedly  suggested  this  popular  name  for  cystitis. 

In  conclusion,  the  general  significance  of  chronic  catarrhal  inflammation 
is  explained  when  we  recognize  that  some  constantly  acting  cause  is  produc- 
ing an  injurious  effect  upon  an  exposed  mucous  membrane;  and  the  theory 
of  its  cure  is  mainly  based  upon  the  removal  of  this  cause. 


Inflammation  in  the  Scrofulous. 

The  scrofulous  catarrh  of  early  life  has  just  been  mentioned  as  presenting 
peculiar  characteristics.  In  truth,  all  the  manifestations  of  inflammation  in 
persons  of  the  scrofulous  diathesis  present  features  so  marked  and  character- 
istic, and  differing  in  so  many  particulars  from  their  ordinary  aspect,  that  it 
is  proper  to  study  inflammation  in  the  scrofulous  as  presenting  one  of  the 
most  important  varieties  of  the  process. 

This  constitutional  diathesis  has  been  always  recognized,  and  its  signs  are 
so  well  known  that  it  is  useless  to  dwell  on  them.  !Nor  is  it  necessary  here 
to  discuss  the  facts  which  seem  to  justify  a  belief  in  the  infective  properties 
of  tubercle,  and  to  differentiate  it  from  scrofula  as  its  sole  source  of  origin. 
It  certainly  finds  a  more  congenial  soil  in  the  scrofulous.  The  influence  of 
the  latter  diathesis  upon  the  series  of  vascular  and  textural  changes  following 
injury,  principally  concerns  us,  and,  after  stating  categorically  the  several 
modes  in  which  this  influence  is  manifested,  we  shall  endeavor  to  reach  the 
safest  basis  for  treatment  of  inflammation  in  the  scrofulous. 

It  is  in  early  life  that  the  characteristics  of  scrofula  are  most  apparent. 
They  are  seen  in  the  tendency  to  enlargement  of  the  lymphatic  glands,  and  in 
the  proclivity  to  certain  forms  of  skin  eruption,  and  to  disease  of  the  joints  and 
bones.  The  effort  required  for  growth  and  development  at  this  period  of  life, 
seems  to  overtax  the  defective  vital  powers  of  those  who  inherit  or  acquire 
the  diathesis.  The  lack  of  vital  power  manifests  itself  primarily  in  the  quality 
of  the  blood,  and  consequently  in  the  want  of  vigor  and  effectiveness  in  the 
nutritive  machinery,  and  in  the  defective  quality  of  the  tissues  and  organs 
just  indicated,  but  especially  in  the  vascular  tissue.  There  is  apparently  less 
want  of  power  in  growth,  than  in  development ;  and  this  is  shown  mainly 
in  this  lack  of  textural  quality.  A  scrofulous  child  grows  finely  for  several 
years,  and  then,  without  any  adequate  cause,  is  overtaken  by  meningitis,  or 
by  disease  of  the  vertebne.  The  same  peculiarity  in  textural  development  is 
manifest  in  the  repair  of  injuries  in  the  scrofulous.  In  the  process  of  con- 
structive inflammation,  cell  production  and  germination  are  prompt  and  pro- 
fuse, but  the  subsequent  development  of  the  cells  into  healthy  tissue  for 
complete  and  perfect  repair  is  liable  to  fail. 

Thus  a  sprained  ankle  which,  in  a  growing  girl  of  healthy  constitution, 
would  get  well  certainly  in  two  or  three  weeks,  in  a  scrofulous  child  may  fail 
entirely  to  recover,  and  may  become  the  starting  point  of  chronic  disease  of  the 
joint.  It  is  defect  in  vital  quality  and  power  in  the  vascular  tissue  that  ex- 
plains such  results  as  this,  which  are  not  uncommon  in  the  scrofulous.  Capil- 
lary vessels  are  not  formed  rapidly  enough  in  the  organizing  granulation 
tissue  to  furnish  a  sufficient  supply  of  blood ;  hence  its  constituent  cells  cease 
to  develop ;  they  linger  in  an  overgrown  but  unnatural  attitude,  constituting 
the  material  that  gives  its  name  and  its  fusiform  shape  to  that  form  of  white 
swelling  known  as  gelatiniform  degeneration.  The  want  of  an  adequate 
blood-supply  leads  to  other  changes  in  the  growing  cells :  they  undergo  fatty 


184  INFLAMMATION. 

degeneration,  and  become  transformed  into  a  yellowish  material  with  the 
appearance  and  consistence  of  soft  cheese.  This  material  has  heretofore  been 
regarded  as  tubercle ;  but  it  is  now  rendered  exceedingly  probable  that  it  is, 
in  the  majority  of  cases,  nothing  more  than  a  result  of  degeneration  of  the 
constructive  materials  contributed  for  a  reparative  purpose  in  the  normal 
course  of  the  inflammatory  effort,  but  not  sufficiently  supplied  with  blood  to 
secure  their  development  into  tissue. 

The  real  nature  of  the  true  tubercular  deposit  is  not  yet  certainly  deter- 
mined ;  but  there  seems  to  be  evidence  that  it  is  generated  more  readily  and 
with  greater  frequency  in  the  scrofulous,  although  by  no  means  necessarily, 
or  invariably  ;  and  that,  when  thus  generated,  it  tends  to  produce  more  rapid 
and  mischievous  results.  Histology  teaches  at  present,  mainly  on  the  autho- 
rity of  Rindneisch,  that  in  the  inflammatory  process  in  the  scrofulous,  the  exu- 
dation cells  are  unusually  large ;  that  the  white  blood  corpuscles,  after  escaping 
through  the  walls  of  the  capillaries,  take  on  ampler  proportions  than  in 
healthy  subjects.  It  is  asserted  that,  in  consequence  of  their  size,  their  ab- 
sorption by  the  lymphatics  is  rendered  more  difficult,  as  they  cannot  enter 
these  vessels ;  and  that  this  circumstance  explains  the  slow  disappearance  of 
inflammatory  induration  in  the  scrofulous.  Whether  this  be  true  or  not,  it 
has  become  sufficiently  apparent  why  constructive  inflammation  is  more  slow 
and  imperfect  in  its  results  in  the  individuals  of  this  diathesis;  and,  also,  that 
their  tissues  possess  less  power  to  resist  destruction  and  waste  in  the  way  of 
suppuration ;  and  that  inflammation  in  them  has  a  greater  tendency,  under 
all  circumstances,  to  take  on  the  chronic  character. 

In  consequence  of  the  difficulty  and  delay  that  attend  tissue  formation,  it  is 
not  easy  to  bring  a  suppurating  surface  to  the  point  of  cicatrization.  The 
granulations  are  usually  pale,  flabby,  and  scanty ;  and  they  bear  gently  stimu- 
lating applications  with  advantage.  Hence  the  benefit  derived  from  the  injec- 
tion of  alcohol  in  the  dermic  abscesses  of  children.  Hence,  also,  as  regards 
the  whole  organism,  with  its  equivalent  defective  qualities,  comes  the  benefit 
derived  from  the  purer  air  of  the  country,  the  more  concentrated  forms  of 
food  such  as  cod-liver  oil  and  malt,  and  the  drugs  which  increase  the  quan- 
tity of  the  nutritious  constituents  of  the  blood,  such  as  iron  and  the  hypo- 
phosphites. 


Inflammation  in  the  Syphilitic. 

The  permanent  change  impressed  upon  the  blood,  and  consequently  upon 
the  whole  organism,  by  the  presence  in  it  of  the  peculiar  virus  or  poison  of 
syphilis,  is  justly  regarded  as  equivalent  to  a  diathesis.  Although  the  pro- 
cess of  repair  of  injuries  is  usually  effected  in  a  normal  manner  in  the  syphi- 
litic, yet  some  uncertainty  is  always  present  as  to  the  possible  occurrence  of 
irregular  symptoms  due  to  the  presence  of  the  poison  in  the  system.  A  higher 
law,  so  to  speak,  seems  to  prevail  in  certain  systemic  diseases,  which  confers 
a  paramount  power  upon  the  directly  nutritive  function  as  regards  its  con- 
structive manifestations.  A  patient  suffering  from  cancer,  is  more  liable,  in 
some  phases  of  the  disease,  to  fracture  of  bone.  This  accident  has  occurred 
from  simply  changing  the  position  of  a  patient  in  bed;  and  yet  union  of  the 
fracture  lias  followed  in  the  usual  time. 

Most  of  the  manifestations  of  syphilis  are  inflammatory  in  their  character. 
There  is  a  tendency  to  local  hypereemia  or  congestion,  and  also  to  exudation, 
provoked  by  the  irritating  quality  of  the  poison  present  in  the  blood,  and, 
also,  to  cell  germination,  and,  in  a  vague,  purposeless  ^'ay,  to  the  formation 
of  fibroid  tissue.     These  manifestations  have  the  peculiarity  of  occurring  in 


TERMINATIONS   OF   INFLAMMATION.  135 

limited  areas  or  spots,  as  in  the  papular  or  so-called  tubercular  eruptions  of 
syphilis.  Nodes,  and  the  characteristic  gummatous  tumors  which  appear  late 
in  the  disease,  are  results  of  the  same  tendency  to  new  growth  of  a  peculiar 
inflammatory  character.  In  the  latter,  there  is  evidence  of  inability  to  sus- 
tain constructive  action,  as  shown  in  a  tendency  to  central  softening  and  sub- 
sequent absorption,  after  which  a  depressed  cicatrix  is  left;  or,  to  suppuration 
and  ulceration — the  latter  often  extending  in  such  a  way  as  to  show  that  the 
poisoned  blood  has  produced  in  the  tissues  a  defective  vitality;  a  weakness,, 
and  an  inability  to  resist  progressive  destruction. 

The  most  interesting  feature  of  the  syphilitic  inflammations  is  that  in  most 
instances  they  are  promptly  controlled  by  certain  drugs — mercury  and  iodine 
— which  possess  a  remarkable  power  as  antidotes  to  the  poison  upon  the  pre- 
sence of  which  in  the  organism  the  disease  depends. 


Terminations  of  Inflammation. 

The  object  and  end  of  the  local  disturbance  of  nutrition  which  we  call  in- 
flammation, is  the  repair  of  injury,  or  the  removal  from  the  organism  of 
locally  injurious  influences.  In  the  accomplishment  of  this  end,  and,  indeed, 
when  it  fails  in  its  accomplishment,  there  are  certain  incidents  liable  to  occur 
during  the  process,  which  surgical  writers  have  added  to  the  simple  facts  of 
its  result  in  success  or  failure,  and  described,  technically,  as  terminations  of 
inflammation.  Thus,  besides  simple  subsidence  and  disappearance  of  symp- 
toms (resolution),  and  absolute  failure  (gangrene),  pus  formation  and  ulceration 
have  both  been  added  to  the  category  of  "terminations  ;"  and,  by  some,  indu- 
ration and  chronic  inflammation  are  also  included. 

According  to  our  present  view  of  the  subject,  there  are  but  three  ways  in 
which  the  inflammatory  process  may  be  correctly  said  to  terminate : — 

(1)  By  resolution,  in  which  all  the  inflammatory  symptoms,  which  may 
have  been  provoked,  gradually  lose  their  intensity  and  disappear;  the  affected 
parts  resuming,  as  far  as  possible,  their  normal  condition.  This  termination 
takes  place,  as  a  rule,  where  the  injury  has  not  been  severe  in  its  character, 
and  the  progress  of  the  inflammation  proportionally  mild,  that  is,  confined  to 
its  constructive  phase. 

(2)  By  formation  of  new  tissue.  In  the  repair  of  injury,  the  production  of 
a  new  growth  of  tissue  is  the  main  resource  by  which  this  object  is  attained 
by  inflammation.  In  the  simplest  form  of  union,  by  primary  adhesion,  as 
well  as  in  a  breach  of  continuity  attended  by  loss  of  substance,  where  a  mass 
of  granulations  is  organized  into  a  cicatrix,  formation  of  new  tissue  is  the 
all-important  feature,  as  well  as  the  final  result,  of  the  inflammatory  process. 
It  is  for  this  purpose  that  inflamed  parts  tend  to  revert,  at  once,  to  their  em- 
bryonic state  as  the  first  stage  of  organization  and  development.  The  forma- 
tion of  new  tissue,  therefore,  is  properly  recognized  as  a  termination  of  in- 
flammation. 

(3)  By  gangrene,  or  local  death.  This  termination  conveys  the  idea  that  an 
inflammatory  effort  to  repair  an  injury  has  failed  in  its  purpose,  and  that  the 
injured  part  has  died.  The  local  death  results  from  the  ineffectual  working 
of  the  nutritive  machinery  in  the  constructive  attempt:  ineffectual,  because 
the  injury  has  involved  the  capillaries  and  the  connective  tissue  surrounding 
them  to  such  an  extent  as  to  impede  their  functions  and  to  render  the  injury 
irreparable  by  the  resources  of  the  organism ;  or  because  obstacles  have 
arisen  at  a  later  period  wdiich  have  thwarted  the  reparative  effort,  and  left 
the  injured  parts  to  die. 


136  INFLAMMATION. 

There  are  points  which  may  be  profitably  noticed  in  connection  with  each 
of  these  terminations  of  inflammation. 

Resolution. — In  resolution,  the  exudation  which  nas  caused  the  swelling 
undergoes  absorption  by  the  agency  of  the  lymphatics.  Its  more  serous  por- 
tions are  absorbed  directly  and  rapidly.  The  same  is  true  of  the  leucocytes 
and  wandering  cells,  which  are  said  to  find  their  way  readily  into  the  lym- 
phatics, but  the  process  may  be  somewhat  slower.  Rindfleisch's  opinion  has 
already  been  noticed,  that  the  exudation  cells  in  scrofulous  inflammations  are 
often  exceptions  to  this  method  of  absorption,  in  consequence  of  their  larger 
size.  Under  some  circumstances  the  exudative  products,  when  partially  de- 
veloped, undergo  liquefaction,  or  degeneration,  and  subsequent  absorption. 
Although  in  the  process  of  resolution  inflamed  parts  are  said  to  return  to 
their  normal  condition,  this  is  not  absolutely  true  under  all  circumstances. 
The  changes  impressed  upon  the  vessels  and  nerves  by  the  excessive  nutritive 
effort,  leave  traces  of  their  effects  in  what  is  called  "weakness"  of  the  parts. 
The  evidence  of  this  weakness  is  recognizable  in  certain  modifications  of  sen- 
sibility, e.g.,  increased  liability  to  pain  ;  a  deeper  discoloration  of  the  surface 
under  circumstances  which  invite  it,  as  in  a  warm  bath,  through  passive  con- 
gestion of  the  capillaries  which  have  been  overstretched ;  and  proneness  to 
take  on  inflammatory  action  without  sufficient  cause. 

Tissue  Production. — The  occurrence  of  tissue  production  as  a  final  purpose 
or  termination  of  inflammation,  which  is  recognized  by  all  recent  authorities, 
is  a  culminating  proof  of  the  original  reparative  intention  of  the  process. 
Whether  in  union  by  primary  adhesion,  in  the  process  of  healing  under  a 
scab,  in  subcutaneous  consolidation,  in  the  secondary  adhesion  of  granulations, 
or  in  the  accomplishment  of  cicatrization  after  protracted  suppuration,  tissue 
production  is,  in  all,  the  medium  by  which  the  final  purpose  of  repairing  in- 
juries is  achieved. 

In  primary  union,  the  increased  nutritive  effort  may  be  scarcely  recogniz- 
able by  the  presence  of  any  of  the  symptoms  of  inflammation,  and  its  result 
may  be  a  barely  perceptible  linear  cicatrix,  and  yet  this  result  has  been  brought 
about  by  tissue  production.  Newly  developed  capillary  loops  are  passing 
across  the  chasm  through  a  delicate  layer  of  granulation  tissue,  just  organized. 
All  the  earlier  phenomena  of  the  inflammatory  process :  increased  rapidity 
of  capillary  circulation,  dilatation — afflux,  in  short — and  exudation,  have  this 
end  in  view.  This  becomes  apparent  if  we  study  these  phenomena  in  the 
variations  they  present  in  inflammation  as  seen  in  the  several  original  tissues 
of  the  body,  varieties  due  to  the  different  ways  in  which  their  nutritive  blood- 
supply  is  accomplished,  mainly  as  regards  the  size  and  peculiar  arrangement 
of  capillary  vessels.  Thus,  the  process  as  it  occurs  in  bone  explains  the  rea- 
son of  its  exceeding  slowness,  and,  at  the  same  time,  illustrates  the  unerring 
tendency  to  reversion  to  the  embryonic  condition  in  order  to  reach  the  result 
of  tissue  production.  The  Haversian  canals  of  the  bony  tissue  enlarge  by 
absorption  of  their  walls,  in  order  that  sufficient  vascular  distension  may 
take  place  under  the  influence  of  the  afflux,  to  secure  exudation.  Stimulated 
by  the  exudation,  as  soon  as  it  has  taken  place,  the  adjacent  cells  begin  to 
germinate,  and  thus  absorption  of  bone  goes  on  until  it  becomes  replaced  by 
embryonic  or  granulation  tissue,  in  which,  in  due  time,  the  earthy  salts  are 
deposited,  and  the  formation  of  callus  accomplished.  In  case  of  an  obstacle 
to  its  accomplishment,  the  conversion  of  bone  into  embryonic  tissue  goes  on 
in  a  purposeless  way,  a  collection  of  pus  takes  place,  or  the  process  lapses  into 
a  chronic  stage,  constituting  caries,  or  chronic  osteitis.  In  a  similar  manner, 
but  more  rapidly,  the  peculiar  substance  of  muscle,  tendon,  or  even  of  nerve, 


TERMINATIONS   OF   INFLAMMATION.  137 

is  reproduced  by  the  process  of  constructive  inflammation.  Surgical  expe- 
rience furnishes  evidence,  in  restoration  of  function,  of  the  fact  of  reproduc- 
tion ;  but  of  the  mechanism  by  which  it  is  brought  about  in  the  more  com- 
plex tissues,  the  nerves  for  example,  we  are  not  yet  fully  informed. 

The  most  common  example  of  tissue  production,  for  obvious  reasons,  takes 
the  form  of  connective  tissue ;  and  this  occurs  primarily,  replacing  the  more 
complex  tissues,  as  in  the  case  of  bone,  muscle,  and  nerve  substance,  until 
more  perfect  reproduction,  requiring  additional  time,  can  be  elaborated.  When 
this  latter  result  is  not  attainable,  parts  are  permanently  replaced  by  connective 
tissue,  as  in  most  instances  in  which  muscular  fibres  have  been  cut  across  in 
a  wound,  and  in  fibrous  anchylosis  of  a  joint.  Where  obstacles  exist  by  which 
reparative  tissue  production  is  hindered,  the  nutritive  materials  furnished  for 
new  growth  are  wasted,  as  pus ;  the  main  end  or  purpose  of  the  constructive 
inflammation  being  held  in  abeyance,  awaiting,  as  it  would  seem,  a  more 
favorable  opportunity. 

But  suppuration,  occurring  under  the  circumstances  just  described,  or,  in 
fact,  under  any  circumstances,  is  in  no  sense  a  termination  of  inflammation  ; 
it  is  simply  an  incident — in  many  cases  an  accident — of  the  process,  as  we 
have  shown  alread}7.  In  the  same  sense  ulceration  is  incidental  to  the  sup- 
purative process,  and  not  correctly  called  a  termination  of  inflammation.  It 
is  an  incident  analogous  to  the  absorption  of  the  walls  of  the  vascular  canals 
in  bone,  acting  solely  in  furtherance  of  the  general  process. 

When  inflammation,  having  been  acute,  subsides  into  a  subacute  or  chronic 
stage,  it  is  obviously  not  proper  to  speak  of  it  as  having  terminated  in  chronic 
inflammation.  The  inflammation,  in  fact,  has  not  terminated  ;  it  has  merely 
lapsed  into  another  phase,  in  which,  in  most  instances,  it  is  awaiting  the  final 
achievement  of  a  purpose  which  has  been  obstructed  and  delayed"  In  this 
view  it  is  also  obvious  that  the  accumulation  of  nutritive  material  in  the  form 
of  induration  cannot  be  admitted  as  a  termination  of  inflammation.  The 
hyperplastic  formation  is  simply  nutritive  material  diverted  from  its  original 
purpose. 

Gangrene,  as  a  termination  of  inflammation,  depends  essentially  upon  the 
amount  and  nature  of  the  injury,  and  especially  upon  the  degree  in  which  the 
capillary  and  larger  nutrient  vessels  are  unfitted  for  carrying  on  the  local 
circulation.  When  the  vitality  of  the  vessels  is  seriously  impaired,  stasis 
and  thrombosis  may  occur,  and  the  capillaries  may  be  prevented  from  carry- 
ing on  their  functions  as  they  do  under  circumstances  of  less  grave  injury  ; 
consequently,  local  death  becomes  imminent.  If  actual  death  takes  place  in 
a  limited  area  by  this  mechanism,  the  presence  of  the  dead  tissue,  offering  an 
additional  obstacle  to  the  local  circulation,  and  additional  provocation  to 
afflux  for  its  elimination,  tends  to  favor  the  extension  of  the  area  of  dying 
and  dead  tissues,  and  in  this  way  spreading  gangrene  is  explained.  Thus  the 
afflux  of  blood  to  repair  injury  becomes,  by  its  obstructive  influence  upon  the 
damaged  vessels,  in  reality  an  additional  cause  of  textural  death ;  and  in  this 
sense  parts  may  be  said  to  be  killed  by  gangrene.  This  premature  termina- 
tion of  the  reparative  eftbrt  in  local  death,  as  in  gangrene  from  other  causes 
than  inflammation,  is  due,  therefore,  to  an  obviously  material  cause,  namely, 
an  inadequate  blood-supply. 

The  local  action  of  poisons  upon  the  tissues,  especially  upon  the  capillaries, 
may  impair  their  vitality  in  a  remarkable  degree.  This  is  illustrated  by  the 
well-known  experiment  of  Ryneck,  who  injected  the  bloodvessels  of  a"  frog 
with  a  solution  of  chromic  acid,  destroying  their  power  of  reacting:  under 
ordinary  stimuli.     The  singularly  rapid  serous  exudation  that  follows  in 


138  INFLAMMATION. 

some  cases  the  sting  of  a  wasp  or  a  hornet,  or  the  bite  of  a  venomous  snake, 
is  probably  clue  to  this  cause. 

The  recognition  of  gangrene  may  be  for  the  moment  a  matter  of  doubt ; 
within  a  day  or  two  after  a  serious  fracture  of  the  leg,  the  coincidence  of  a 
livid  color  of  the  surface,  from  the  ecchymosis  of  contusion,  with  large  vesi- 
cations— a  not  unfrequent  occurrence — is  very  suggestive  of  this  condition. 
Similar  bulla?  containing  bloody  serum  often  form  in  erysipelas,  and  the 
black  patches  which  they  leave  on  drying  have  been  mistaken  for  spots  of 
commencing  gangrene.  But  the  sensibility  elicited  by  the  prick  of  a  needle, 
and  the  absence  of  odor,  will  decide  the  question.  It  has  been  truly  said 
that  the  earliest  symptoms  of  gangrene  are  usually  those  of  intense  inflam- 
mation ;  the  swelling  is  hard,  the  pain  burning  and  tensive,  and  the  color 
livid.  The  pain  then  subsides,  vesications  make  their  appearance,  and  the 
parts  put  on  a  marbled  purplish-yellow  tint  which  afterwards  becomes  brown 
or  grayish.  Finally  they  become  cold  and  insensible,  and  exhale  a  putrid 
odor. 


Treatment  of  Inflammation. 

The  treatment  of  inflammation,  an  account  of  which  will  close  this  article, 
is  necessarily  derived,  as  far  as  it  is  logically  consistent  with  inductive 
reasoning,  from  facts  and  considerations  concerning  the  nature  and  causes  of 
the  process,  such  as  those  which  have  been  somewhat  imperfectly  passed  in 
review.  But  much  that  is  most  valuable  in  the  practical  management  of 
inflammation,  is  derived  from  clinical  observation  and  experience,  and  not 
from  reasoning ;  and  it  is,  therefore,  empirical.  The  mode  of  action  of  some 
of  the  remedial  measures  which  have  been  found  most  effective  in  practice, 
cannot  be  satisfactorily  explained,  in  consequence  of  our  imperfect  knowledge. 
In  the  practical  treatment  of  inflammation,  the  surgeon  is,  therefore,  com- 
pelled to  adopt  an  attitude  of  intelligent  empiricism.  He  follows  the  course 
which  has  seemed  to  be  the  best,  without  rejecting  what  he  cannot  explain, 
relying  upon  the  steady  growth  of  more  accurate  and  precise  knowledge  to 
throw  light  upon  the  mofjius  operandi  of  some  of  his  best  remedies. 

In  the  preceding  pages  much  space  has  been  given  to  the  causes  of  inflam- 
mation, in  the  belief  that  their  study  offers  the  best  illustration  of  its  nature ; 
and  it  has  been  assumed  that  this  course  would  lead  at  the  same  time  to  an 
intelligent  comprehension  of  the  rational  principles  of  treatment.  One  fact 
has  been  rendered  apparent  by  the  study  of  inflammation  from  this  point  of 
view,  namely,  that  it  is  the  normal  tendency  of  inflamed  parts  to  return  to  a 
condition  of  health  as  soon  as  the  causes  which  produced  the  inflammation 
have  been  removed.  In  all  that  belongs  to  this  department  of  the  subject, 
this  important  fact,  which  lies  at  the  foundation  of  all  treatment,  is  to  be 
kept  constantly  in  view. 

It  is  at  once  obvious  that  a  large  share  of  our  ability  to  control  the  mani- 
festations of  inflammation',  comes  from  the  knowledge  by  which  we  are  enabled 
to  foresee  and  avoid  the  action  of  causes,  both  predisposing  and  exciting, 
which  clinical  experience  1ms  shown  to  be  capable  of  provoking  the  inflam- 
matory condition.  Thoughtful  and  intelligent  prevention  will,  therefore, 
necessarily  constitute  an  important  share  of  the  surgeon's  duty  in  his  rela- 
tions to  inflammation,  and  it  should  receive  our  especial  attention.  The 
immunity  from  suppuration  and  the  other  manifestations  of  destructive  in- 
flammation promised  by  thoroughly  carrying  out  the  antiseptic  methods  of 
treating  wounds,  which  will  be  made  the  subject  of  a  separate  article,  serves 


TREATMENT    OF    INFLAMMATION.  139 

to  illustrate  the  great  and  growing  value  of  one  of  the  forms  of  the  preventive 
treatment  of  inflammation. 

Next  in  order,  and  second  only  to  prevention  in  importance,  is  the  detection 
and  removal  of  the  causes  which  have  provoked  inflammation  and  are  keeping 
it  up ;  and  here  is  a  source  of  the  great  interest  which  attaches  to  the  study 
of  these  causes.  As  examples  of  the  importance  of  this  indication  for  treat- 
ment, we  may  refer  to  the  prompt  improvement  that  follows  the  removal  of 
a  splinter  which  is  keeping  up  a  festering  sore,  of  a  foreign  body  in  contact 
with  the  conjunctiva,  of  a  stone  from  the  bladder,  of  a  nail  from  its  inflamed 
matrix  (as  in  onychia),  or  of  a  sequestrum  of  bone  which  has  been  keeping 
up  the  discharge  from  a  sinus.  Mr.  Simon,  who  has  so  ably  discussed  this 
subject,  remarks  with  great  justice  that  "  it  is  amongst  the  highest  prob- 
lems of  pathology  to  discover  new  groups  of  cases  capable  of  being  treated 
like  the  above  by  the  simple  removal  of  their  respective  causes.  With  the 
various  dyscrasial  inflammations,  for  instance,  which  are  now  treated  exclu- 
sively from  an  empirical  basis,  and  consequently  often  without  success,  how 
great  an  achievement  it  would  be,  if  their  immediate  causes  could  be  made 
as  palpable  as  the  mechanical  causes  just  spoken  of,  and  could,  like  them,  be 
distinctly  aimed  at  and  destroyed1." 

A  third  indication  of  paramount  importance  in  the  treatment  of  inflamma- 
tion, is  to  secure  favorable  conditions  for  the  inception  and  progress  of  construc- 
tive inflammation,  or  repair.  From  this  form  of  the  inflammatory  condition, 
which  is  absolutely  necessary  for  the  healing  of  wounds  and  injuries,  every- 
thing is  to  be  hoped.  Its  management  requires  all  possible  means  for  its  pro- 
tection from  interference,  and  for  the  promotion  of  its  objective  purpose — 
which  is  a  termination  by  resolution,  or  cicatrization,  coincident  with  healthy 
repair  of  the  injury  by  which  it  has  been  provoked.  Of  these  means  the  most 
important  are :  rest,  as  nearly  perfect  as  possible,  for  the  whole  body,  and 
especially  for  the  injured  part;  quiescence  for  the  mind,  as  far  as  it  is  attain- 
able; freedom  from  sources  of  external  irritation — including  protection  of  an 
external  wound  from  the  air;  the  best  position  for  the  injured  part  that  can 
be  secured — to  promote  relief  from  pain  and  equable  local  circulation;  an  equa- 
ble temperature  and  purity  of  air,  with  an  adequate  supply  thereof.  These 
and  other  means  useful  for  the  same  end  will  be  considered  more  at  length 
hereafter. 

The  proper  temperature  for  an  injured  part  is  between  68°  and  72°  Fahren- 
heit. Frequent  changes  above  or  below  these  limits  are  incompatible  with 
equability.  For  a  healthy  granulating  wound,  even  a  higher  local  tempera- 
ture is  not  undesirable.  Embryonic  development  takes  place  normally,  within 
the  natural  body,  at  blood  heat.  It  may  be  inferred  that  cell  germination  and 
the  development  of  granulation  tissue,  which  are  identical  processes,  would 
be  favored  by  a  similar  temperature.  In  any  event,  sudden  chilling  of  a  gra* 
nulating  surface  should  be  scrupulously  avoided.  It  has  been  known  to  pro- 
duce a  fatal  invasion  of  traumatic  tetanus.1  Addison  tells  us  that  in  the  arti- 
ficial incubation  of  the  chick,  the  process  is  interrupted  if  the  temperature  falls 
below  the  normal  standard  of  the  female  bird,  which  is  higher  than  the  human 
standard,  namely  106°  Fahr.,  and  the  vitality  of  the  chick  is  endangered. 

This  is  not  the  place  to  enforce  the  necessity  of  an  adequate  supply  of  oxy- 
gen to  secure  the  favorable  progress  of  all  processes  involving  unusual  demands 
upon  the  powers  of  the  organism,  but  the  importance  of\fhis  condition  for 
successful  treatment  of  surgical  injuries  is  constantly  liable  to  be  undervalued. 

•  Agnew,  ut  supra. 


140  INFLAMMATION. 

An  ample  air  supply  is  a  condition  indispensable  for  health,  and  it  is  there- 
fore a  duty  incumbent  upon  those  who  have  charge  of  the  sick,  to  secure  for 
them  their  still  more  urgent  rights  in  this  respect.  The  minimum  supply  for 
each  patient  in  the  ward  of  a  hospital  is  two  thousand  cubic  feet.  The  mor- 
tality in  typhus  fever  has  reached  its  lowest  figure,  even  in  the  uncertain  win- 
ter climate  of  this  latitude,  in  patients  treated  under  canvass,  and  in  temporary 
wooden  houses. 

The  fourth  and  final  indication  for  the  treatment  of  inflammation  includes 
all  the  means  at  our  command  for  the  mitigation  and  control  of  its  manifesta- 
tions when  excessive,  or  when  threatening  to  become  destructive ;  and  for 
their  arrest  when  actually  destructive.  These  comprise  remedies  competent  to 
antagonize  excessive  manifestations,  to  repress  their  intensity,  and  to  restrain 
them,  if  possible,  within  the  limits  of  the  constructive  process. 

The  means  at  our  command  for  meeting  the  requirements  of  the  third  and 
fourth  indications  will  be  discussed  under  the  following  titles:  rest  and 
immobility >•  position;  cold;  heat  and  moisture;  compression;  blood-letting ; 
drainage ;  revulsion ;  drugs  ;  diet  and  nursing. 

Prevention. — But  foremost  in  order  comes  prevention.  "We  are  to  under- 
stand by  the  preventive  treatment  of  inflammation,  the  employment  of  meas- 
ures which  tend  to  favor  the  process  of  repair — that  phase  of  the  inflamma- 
tory process  which  we  have  called,  after  Samuels,  constructive ;  and,  also, 
the  means  at  our  command  to  avert  any  excess,  or  to  remedy  any  defect,  of 
vascular  action,  which,  besides  defeating  the  reparative  object  of  the  process, 
would  produce  waste  and  destruction  of  tissue — constituting  the  phase  of 
inflammation  we  have  called  destructive.  The  former  is  to  be  promoted ; 
the  latter  to  be  avoided,  and,  if  possible,  prevented.  Happily,  in  the  great 
majority  of  cases,  both  of  these  ends  are  to  be  attained  by  the  same  means. 
When  we  have  secured  complete  primary  adhesion  in  a  recent  wound,  as  a 
rule,  all  danger  from  inflammation  is  at  an  end. 

Keeping  always  in  view  the  fact  that  inflammation  is  nothing  more  than 
an  exaggerated,  sometimes  a  perverted,  effort  on  the  part  of  the  local  nutri- 
tive apparatus  to  meet  some  emergency  in  which  the  integrity  of  the  organ- 
ism is  threatened,  our  first  duty  is  to  favor  in  every  way  the  healthy  per- 
formance of  the  all-important  nutritive  function.  This  is  to  be  accomplished 
by  providing  pure  air  to  breathe,  plenty  of  sunlight,  good  food  to  eat,  with 
proper  attention  to  the  conditions  and  surroundings  by  which  the  normal 
performance  of  all  the  functions  is  promoted.  The  constitutional  peculiarities 
and  acquired  habits  of  life  of  an  individual  who  has  sustained  a  surgical 
injury  should  always  be  made  the  subject  of  careful  inquiry;  and  the 
patient's  habitual  food  and  drink,  and  his  hours  of  eating  and  of  attending 
to  the  calls  of  nature,  should  be  imitated  as  closely  as  circumstances  will 
permit.  He  is  to  be  regarded  as  a  machine,  and  placed  in  all  respects  in  the 
position,  as  to  surroundings,  in  which  the  machinery  will  work  to  the  best 
advantage.  At  the  same  time,  the  influence  of  the  mind  upon  the  healthy 
performance  of  the  physical  functions  is  to  be  kept  in  view;  fear  and  anxiety 
are  as  far  as  possible  to  be  dispelled ;  and  hope  and  confidence  are  to  be  in- 
spired.  As  Claude  Bernard  has  shown,  fear  and  apprehension  of  danger 
tend  to  depress  the  normal  temperature  of  the  body,  which  is  kept  up  by  the 
proper  working  of  the  nutritive  machinery;  whilst  hope  and  happy  antici- 
pations have  ;i  healthy  stimulating  effect. 

The  next  duty  of  the  surgeon  in  preventing  undue  inflammation,  is  the 
avoidance,  ;is  far  as  circumstances  will  permit,  of  all  possible  causes  of  inter- 
ference with  the  process  of  normal  repair,  and  especially  of  the  causes  liable 


TREATMENT    OF   INFLAMMATION.  141 

to  provoke  unhealthy  or  excessive  manifestations.  The  phenomena  attending 
the  reparative  act,  although  forming  a  part  of  the  process  of  inflammation, 
are  to  be  recognized  and  favored ;  not  prevented.  It  is  their  excessive  or 
perverted  action  which  we  have  to  guard  against  by  our  art.  This  subject 
will  be  more  fully  discussed  hereafter.  For  the  present,  to  avoid  repetition, 
we  may  refer  to  the  study  of  predisposing  and  exciting  causes  contained  in 
the  preceding  pages,  with  the  remark  that  the  injurious  action  of  certain 
amongst  them  is  noticeably  preventable.  For  example,  if  a  patient  is  found 
to  be  under  the  influence  of  malaria,  or  if  he  is  confined  to  a  malarial  locality, 
it  would  be  eminently  proper  to  place  him  under  the  prophylactic  influence 
of  quinine ;  in  other  words,  to  make  a  few  grains  of  quinine  a  part  of  his 
daily  diet,  If  he  be  found  to  be  syphilitic,  according  to  the  stage  of  the  con- 
stitutional poisoning — whether  active  or  passive — it  would  be  a  judicious 
course  for  the  surgeon  to  avail  himself  of  the  tonic  and  blood-making  prop- 
erties of  iodine,  or  of  minute  doses  of  the  bichloride  of  mercury. 

But  of  all  the  preventive  measures  within  our  reach  for  the  purpose  of 
avoiding  unhealthy  inflammation  in  the  treatment  of  open  wounds,  the  pre- 
cautions and  means  which  constitute  the  antiseptic  method  of  treating  wounds 
have  of  late  years  grown  into  proportions  of  greatest  magnitude.  Judging 
from  results  alone,  without  attempting  a  decision  as  to  the  theory  on  which 
it  is  based,  placing  himself  on  the  legitimate  ground  of  intelligent  empiricism, 
and  following  the  plan  which  promises  most  benefit  to  his  patient,  the  sur- 

feon  of  to-day  is  forced  by  the  logic  of  facts  to  adopt  the  method  of  Lister, 
'he  cicatrization  of  open  wounds  without  pus  and  without  delay,  as  if  they 
were  subcutaneous,  or  healing  under  a  scab — a  result  which  can  be  com- 
manded with  as  much  certainty  as  attends  any  human  enterprise,  if  the 
details  of  the  antiseptic  method  are  scrupulously  observed — constitutes  one 
of  these  facts.  Another  is  the  greatly  diminished  frequency,  if  not  the  entire 
absence,  of  the  infective  forms  of  inflammation  and  fever  in  surgical  cases 
treated  by  the  antiseptic  method  when  it  has  been  conscientiously  carried  out 
from  the  inception  of  the  case.  But  it  is  to  be  remarked  that  in  the  doubt- 
ing allegiance  of  many,  and  their  consequently  feeble  adhesion  to  the  new 
method,  and  the  carelessness  as  to  details  that  comes  from  want  of  full  faith, 
from  prejudgment  of  the  question,  greater  attachment  to  old  methods,  or  un- 
willingness to  learn  new  and  troublesome  details,  there  are  impediments  which 
interfere  with  its  adoption.  This  will  be  arrived  at  ultimately,  it  is  not  un- 
likely, as  a  consequence  of  the  greater  material  success,  in  the  aggregate,  of 
those  surgeons  who  practise  the  antiseptic  method  in  all  its  details,  and  pos- 
sibly by  improvement  in  those  details.  Meanwhile,  antiseptics  are  gradually 
taking  the  place  of  antiphlogistics ;  the  latter  cease  to  be  thought  of  in^  pro- 
portion as  the  former  grow  in  the  confidence  of  the  profession ;  and  the  opinion 
is,  on  the  whole,  steadily  gaining  ground  that  antiseptics  constitute  the  best 
preventive  measures  against  unhealthy  inflammation. 

Popular  experience  is  not  an  unfair  test  of  the  value  of  local  remedies  in 
preventing  inflammatory  complications.  When  surgery  was  as  yet  unworthy 
to  be  called  a  science,  the  favorite  applications  to  wounds  were  spirituous 
tinctures,  balsamic  substances,  resins,  and  turpentines ;  and  they  undoubtedly 
owed  their  popularity  as  vulneraries  to  their  antiseptic  qualities.  One  of 
them,  with  a  reputation  of  several  centuries,  the  "bamne  du  commandeur" 
praised  by  Ambrose  Pare,  known  in  England  as  "friar's  balsam,"  in  our 
country  as  "  Turlington  balsam,"  has  a  place  in  the  IT.  S.  Pharmacopoeia  as 
the  compound  tincture  of  benzoin.  Many  a  fresh  wound  bound  up  with  this 
vulnerary,  which  is  still  largely  used  in  domestic  practice,  and  afterwards 
left  undisturbed  through  full  confidence  in  its  healing  virtues,  has  got  well 
without  "  inflammation  getting  into  it."     Basilicon  ointment,  ceratum  resince, 


142  INFLAMMATION. 

lias  a  popular  reputation  due  to  the  same  cause.  Alcohol  was  a  favorite 
dressing  for  wounds  with  Nelaton,  and  it  has  had  enthusiastic  advocates.  It 
is  claimed  that  it  coagulates  albuminoid  substances  and  renders  them  impu- 
trescible,  and  at  the  same  time  "  closes  the  smaller  bloodvessels  and  arrests 
their  power  of  absorption."  It  enjoys  a  large  popularity  in  the  form  of 
Cologne  water  and  its  substitutes,  and  of  "  Pond's  Extract."  Spirit  of  cam- 
phor was  the  favorite  lotion  of  the  late  Valentine  Mott ;  and  the  eau  sedative 
of  Raspail,  consisting  mainly  of  camphor  and  common  salt  dissolved  in  alcohol, 
is  a  universal  panacea  in  France. 

Greasy  applications  exclude  the  air,  and,  when  impregnated  with  an  anti- 
septic balsam,  form  the  bases  of  most  ointments  and  salves  used  as  dressings 
for  wounds.  The  Peruvian  ointment  of  the  New  York  Hospital  is  one 
drachm  of  balsam  of  Peru  to  one  ounce  of  simple  cerate.  Vaseline,  which  is 
antiseptic  and  entirely  unalterable  as  regards  rancidity,  is  gradually  replacing 
other  greasy  applications. 

It  is"  noticeable  as  a  feature  of  antiseptic  dressings  of  all  kinds,  that  they 
are  associated  with  infrequency  of  wound  dressing,  mainly,  it  is  to  be  pre- 
sumed, on  account  of  lack  of  evidence  as  to  the  necessity  for  frequent  inter- 
ference. •  This  circumstance  alone,  as  conducing  to  quietude  and  equability 
of  temperature,  favors  rapid  and  healthy  healing ;  and,  other  things  being 
equal,  that  form  of  dressing  which  requires  least  frequent  renewal  is  always 
to  be  preferred  as  a  preventive  of  ill  behavior  of  wounds  through  unhealthy 
inflammation. 

Addison  quotes  the  case  of  a  boy  who  fell  into  a  caldron  of  boiling  pitch.  In 
removing  his  clothing,  the  sleeves  adhered  so  closely  that  they  were  necessarily  left  on 
his  arms.  The  boy  ultimately  recovered ;  but  the  attendant  expressed  surprise  that 
his  arms  had  cicatrized  more  rapidly  and  perfectly  than  the  other  parts  of  the  body 
which  had  enjoyed  the  benefit  of  his  daily  dressing. 

Apart  from  the  question  of  antiseptics,  there  is  abundant  clinical  evidence 
that  the  exclusion  of  air  favors  kindly  healing  and  tends  to  avert  suppuration 
in  surface  lesions  of  the  body,  such  as  abrasions,  and  especially  burns.  On  a 
small  scale,  the  popular  use  of  court  plaster  is  in  point ;  and  the  prompt 
application  of  an  impermeable  dressing  of  gum,  with  the  addition  of  a  little 
molasses  to  give  it  toughness,  so  long  in  use  at  the  New  York  Hospital  as  a 
dressing  for  burns  and  scalds,  has  proved  of  great  value.  A  mixture  of  col- 
lodion and  castor  oil  is  said  to  be  employed  in  the  same  way  at  King's  Col- 
lege Hospital,  in  London. 

Rest  and  Immobility. — The  great  advantages  to  an  injured  part  of  perfect 
rest  and  freedom  from  disturbance  by  movement  of  every  kind,  have  already 
been  enumerated  in  the  remarks  on  motion  as  one  of  the  mechanical  exciting 
causes  of  inflammation.  Their  paramount  importance  in  the  treatment  of 
inflammation,  both  preventive  and  curative,  cannot  be  too  strongly  enforced, 
for  tlie  reason  especially  that  it  is  being  constantly  undervalued,  profession- 
ally rts  well  as  popularly.  The  directions  often  given  to  a  patient,  in  a  per- 
functory way,  1<>  keep  an  injured  part  quiet,  should,  in  most  cases  be  enforced 
by  surgical  appliances  by  which  its  motions  are  rendered  impossible.  A 
patient,  however  intelligent  and  docile,  can  rarely  keep  a  part  quiet  unless  its 
movements  are  physically  restrained,  or  unless  he  is  reminded  to  do  so  by 
the  recurrence  of  pain  on  motion,  and  this  always  involves  additional  injury; 
in  v'kw  of  this  fact,  the  surgeon  should  not  only  advise,  but  enforce  his  advice. 
The  lesson  taught  us  by  the  ill  behavior  of  trifling  lesions  of  parts  subjected 
1m  constant  mobility,  as,  for  example,  the  festering  of  an  abrasion  upon  a 
knuckle,  is  entirely  applicable  to  lesions  of  a  graver  character. 


TREATMENT  OF  INFLAMMATION.  143 

Destructive  inflammation  is  often  provoked  by  inadvertent  motion,  as  in 
the  case  of  a  laborer,  or  a  mechanic,  with  a  spreading  inflammation  of  the 
forearm  following  a  neglected  hurt  of  the  hand,  which  could  have  been  cer- 
tainly prevented  by  timely  precaution  securing  quietude  and  immobility. 
The  average  patient  cannot  understand  that  moving  a  wounded  part  can  do 
it  harm,  as  long  as  the  motion  does  not  give  pain  at  the  moment,  It  is  as 
difficult  for  an  open  wound  to  granulate  or  cicatrize  when  continually  sub- 
jected to  motion,  as  for  a  rosebud  to  bloom  whilst  being  carried  in  a  button- 
hole. Similarly,  a  wrenched  ligament  after  a  sprain  cannot  promptly  regain 
its  integrity  unless  the  part  to  which  it  belongs  is  rendered  immovable ;  nor 
can  an  inflamed  eye  get  well  whilst  the  organ  is  in  constant  use.  Thus 
we  must  recognize  it  as  an  ultimate  fact  established  by  clinical  experience, 
that  too  much  motion  is  as  certain  to  retard  and  pervert  the  process  of  repair, 
as  it  is  to  provoke  and  excite  the  destructive  phases  of  the  inflammatory 
process. 

The  means  at  the  command  of  the  surgeon  by  which  he  can  most  readily 
enforce  quietude  and  immobility  of  a  part  are,  primarily,  splints  and  band- 
ages, or  strips  of  adhesive  plaster.  Even  where  confinement  to  bed  might 
be  thought  sufficient,  as  in  some  forms  of  fracture,  retentive  appliances  are 
generally  indispensable.  In  the  most  firmly  impacted  fracture  of  the  neck 
of  the  femur,  it  would  be  the  best  course  to  render  the  parts  immovable.  The 
so-called  immovable  apparatus,  consisting  of  bandages  hardened  by  gypsum, 
starch,  dextrine,  or  the  silicates,  are  easy  of  application,  and  useful  for  many 
lesions  besides  fracture.  Billroth  states  that  he  has  had  a  greater  degree  of 
success  in  the  treatment  of  sprains  since  he  adopted  the  use  of  the  plaster  of 
Paris  bandage;  and  the  value  of  the  plaster  jacket  in  disease  of  the  vertebral 
processes  and  bodies  has  been  demonstrated  by  Sayre.  Carved  wooden  splints, 
and  guttered  splints  of  tin  or  wire,  prepared  felt,  gutta-percha,  or  sole- 
leather,  which  can  be  moulded  to  the  injured  part,  are  available  for  lesions  in 
the  neighborhood  of  joints,  where  motion  is  especially  to  be  guarded  against. 
For  smaller  wounds,  which  are  always  liable,  when  neglected,  to  become 
sources  of  serious  complication,  strips  of  adhesive  plaster,  collodion,  and  even 
court-plaster,  are  of  value.  In  wounds  of  the  face  where  quick  union  is  espe- 
cially desired,  to  prevent  scars,  the  latter  form  of  plaster,  when  free  from 
coloring  matter,  is  very  useful ;  also  between  minute  sutures  in  plastic  opera- 
tions on  the  face,  collodion  being  applied  over  the  ends  of  the  strips,  but  not 
upon  the  wound  itself. 

For  securing  rest  by  the  relief  of  pain  and  consequent  restlessness,  which  is 
often  a  source  of  additional  injury  after  dressing  a  recent  wound ;  for  every 
form  of  nervous  excitability  accompanying  surgical  lesions;  and  above  all 
for  traumatic  delirium,  which  is  an  expression  of  the  most  intense  form  of 
nervous  excitement — always  excepting  hysteria — opium  in  some  form,  as  the 
typical  anodyne,  is  invaluable.  This  drug  is  of  such  great  importance  as 
an  adjuvant  in  the  treatment  of  inflammation,  through  the  possession  of 
these  qualities,  that  it  has  acquired  a  reputation  as  one  of  its  indispensable 
remedies.  This  reputation  is  due,  in  the  first  place,  to  its  power  in  controlling 
the  symptom  of  pain,  and  in  the  next  place,  to  its  influence  over  muscular 
irritability  and  the  prevention  of  twitching,  spasm,  and  consequent  injurious 
mobility  at  the  seat  of  inflammation.  By  this  latter  quality  its  well-earned 
reputation  in  the  treatment  of  peritonitis  has  been  attained ;  it  not  only  arrests, 
for  the  time,  the  peristaltic  squirming  of  the  intestines,  but  slows  the  action 
of  the  diaphragm,  thus  favoring  the  adhesive  results  of  inflammation,  and 
averting  fatal  suppuration.  Opium  is  in  this  manner  eminently  useful  as  a 
preventive  of  the  destructive  manifestations  of  the  inflammatory  process. 
Hence  after  dressing  a  surgical  case,  and  having  placed  the  injured  part  in  the 


144  INFLAMMATION. 

best  position,  the  next  step  in  treatment  is  to  administer  an  anodyne,  or  to 
leave  directions  for  its  administration  in  case  of  pain  or  restlessness. 

As  is  the  case  with  every  favorite  remedy,  the  power  conferred  by  an  ano- 
dyne of  relieving  mental  distress,  in  most  cases,  as  well  as  physical  pain,  is 
liable  to  be  abused.  An  opiate  should  not  be  administered  unless  a  distinct 
indication  exists,  for  its  use.  In  most  cases  it  interferes  with  the  functions 
of  the  stomach  and  intestines,  and  in  conjunction  with  confinement  to  the 
horizontal  position,  so  often  indispensable  after  a  surgical  injury,  its  employ- 
ment begets  a  necessity  for  laxative  medicine,  and  thus  interferes  with  the 
important  blood-making  function,  and  increases  the  tendency  to  constitutional 
disturbance  and  fever.  Moreover,  the  administration  of  an  anodyne,  espe- 
cially if  its  effect  has  been  pleasant,  often  creates  a  desire  on  the  part  of  the 
patient  for  its  repetition  when,  perhaps,  a  sufficient  indication  is  wanting. 
Thus,  however  much  he  may  be  tempted  to  exercise  his  power,  the  surgeon 
should  be  on  his  guard  against  the  possibility  of  abusing  it ;  he  has  in  trust 
what  has  been  justly  called  one  of  the  greatest  gifts  of  God  to  man,  and  should 
be  careful  to  bestow  it  wisely. 

Position. — The  position  of  a  part  which  has  been  the  seat  of  an  injury  or  a 
surgical  operation,  especially  when  seated  in  a  limb,  should  always  be  con- 
sidered in  reference  to  the  avoidance  of  pain  at  the  time,  and  of  provocation 
to  subsequent  inflammation.  In  this  regard  there  are  several  points  to  be 
noted:  (1)  a  position  should  be  selected  which  favors  the  venous  or  return 
circulation,  so  as  to  avoid  the  danger  of  passive  hyperemia ;  (2)  muscular 
relaxation  is  to  be  secured — as  far  as  possible — in  order  to  guard  against  the 
involuntary  spasmodic  action  liable  to  be  provoked  by  muscular  tension ;  (3) 
if  there  is  a  wound,  the  position  should  be  managed  so  as  to  favor  the  ready 
escape  of  all  possible  discharges ;  and  (4)  the  position  should  be,  as  far  as  pos- 
sible, agreeable  to  the  patient's  feelings. 

It  is  hardly  necessary  to  add  that  undue  manipulation  or  change  of  position 
is  to  be  avoided,  and  where  this  is  absolutely  required,  in  a  case  of  serious 
lesion  involving  much  pain,  as  in  a  compound  fracture,  it  is  often  the  wiser 
plan  to  bring  the  patient  carefully  under  the  influence  of  an  anesthetic  before 
handling  the  part.  The  muscular  relaxation  secured  by  the  anaesthetic,  pre- 
vents spasmodic  contractions  which  do  harm  by  disturbing  the  relations  of 
the  fragments,  and  by  possibly  causing  bleeding.  And,  moreover,  when  an 
anaesthetic  acts  kindly  and  without  causing  undue  excitement  or  subsequent 
vomiting,  it  is  a  matter  of  clinical  observation  that  there  is  less  disposition  to 
excessive  vascular  reaction  after  it  has  been  employed.  As  after  the  admin- 
istration of  opium,  there  seems  to  be  less  tendency  to  undue  inflammatory  ex- 
citement than  where  the  same  amount  of  violence  has  been  inflicted  upon  a 
perfectly  conscious  and  sensitive  patient.  Those  who  have  had  the  experience 
of  undressing  and  opening  a  recently  closed  wound  in  order  to  secure  a  bleed- 
ing artery,  without  the  aid  of  chloroform  or  ether,  can  bear  witness  to  the 
greater  frequency  of  positive  febrile  reaction  after  such  a  double  strain  upon 
the  power  of  endurance. 

Cold. — As  a  cause  of  inflammation,  exposure  to  intense  cold  may  literally 
freeze  exposed  parts,  such  as  the  nose,  ears,  or  toes ;  but  if  the  temperature 
he  very  gradually  elevated,  and  the  suspended  capillary  circulation  be  restored, 
as  by  gentle  friction  with  snow  or  ice-water,  the  parts  may  be  brought  back 
to  a  uormal  or  to  a  very  slightly  weakened  condition.  But  if  the  temperature 
of  I  lie  frozen  parts  be  suddenly  raised,  as  by  entering  a  hot  room  or  approach- 
ing a  stove,  they  are  liable  to  become  intensely  congested,  livid,  and  possibly 
gangrenous ;  or  to  remain  in  a  condition  of  chronic  inflammation,  with  a  lia- 


TREATMENT    OF   INFLAMMATION.  145 

bility  to  itcliing,  vesication,  and  ulceration,  as  in  chilblain.  Tissues  which  have 
been  frozen  offer  an  analogy  to  tissues  which  have  been  poisoned,  in  respect 
of  their  weakened  vitality  and  their  tendency  to  take  on  a  low  degree  of  in- 
flammation readily  and  from  slight  causes.  But  this  weakened  condition 
may,  under  favorable  circumstances,  be  recovered  from  entirely. 

Cold,  in  its  effects  upon  the  system  at  large,  is  distinctly  tonic  and 
"bracing,"  when  it  is  not  too  severe  or  too  much  prolonged.  In  the  latter 
case  it  acts  as  a  powerful  sedative  to  all  the  functions  of  life,  producing  an 
intense  desire  to  sleep,  and  finally  death,  in  stupor,  by  the  arrest  of  function  of 
the  cells  which  generate  nerve  force,  as  in  fatal  collapse  from  shock  of  injury. 
Locally  applied,  cold — -judiciously  regulated  as  to  its  degree  and  mode  ot 
application — is  regarded  as  a  valuable  means  of  diminishing  the  force  of  the 
circulation,  and  thereby  of  antagonizing  a  tendency  to  excessive  vascular  ex- 
citement in  the  earlier  phases  of  inflammatory  action.  It  acts  not  only  as  a 
local  sedative,  but,  also,  as  an  astringent. 

Cold  is  usually  applied  by  covering  the  part  with  a  cloth  wrung  out  of  iced 
water,  or  saturated  with  an  evaporating  lotion.  The  latter  form  of  applica- 
tion was  habitually  employed  before  ice  came  into  general  use.  As  these 
applications  tend  to  become  soon  dried  by  the  heat  of  the  body,  if  a  part  is 
to  be  kept  steadily  at  a  lower  temperature,  they  must  be  renewed  at  short 
intervals.  This  demands  attentive  nursing,  for  frequent  change  of  tempera- 
ture in  a  part,  certainly  in  the  early  stage  of  inflammation,  is  harmful.  These 
modes  of  applying  cold  are  well  replaced  by  systematic  irrigation.  If  a  vessel 
of  iced-water  be  suspended  above  the  part  to  be  irrigated,  and  some  strands 
of  lamp  wick  be  placed  with  one  end  at  the  bottom  of  the  vessel  and  the 
other  hanging  over  its  side,  the  cold  water  can  be  made  to  drop  steadily  and 
continuously  upon  the  cloth  that  covers  the  part.  But  a  sheet  of  impermeable 
material  must  be  placed  beneath  the  part,  so  as  to  convey  away  the  overflow, 
or  the  bedclothes  will  become  saturated,  and  the  patient's  body  possibly  chilled. 
Cold  with  moisture,  inopportunely  brought  to  bear  upon  the  organism,  is  a 
fertile  cause  of  harm  in  many  ways.  A  greater  degree  of  cold,  as  a  local  ap- 
plication, may  be  secured  when  desirable  by  means  of  a  caoutchouc  bag,  or 
bladder,  filled  with  crushed  ice  and  moulded  to  the  part. 

Cold,  applied  locally,  has  always  been  regarded  favorably  and  employed 
largely  in  the  treatment  of  inflammation,  and  it  certainly  possesses  power, 
and  a  certain  degree  of  value ;  but  in  practice  its  use  is  limited,  because,  as  is 
evident,  it  involves  trouble  and  care,  and  it  is  also  undoubtedly  capable  of 
doing  harm,  if  not  employed  with  good  judgment.  In  the  first  place,  it  is 
not  well  suited  for  open  wounds  ;  for  granulations,  as  we  have  seen,  are  aided 
in  their  germination,  growth,  and  development,  by  a  warm  temperature. 
Where  a  wound  has  been  closed  with  a  view  to  primary  adhesion,  dry  dress- 
ing suits  better,  in  connection  with  the  gentle  and  equable  pressure  by  which 
this  mode  of  union  is  promoted.  Neither  positive  cold,  nor  the  alternations 
of  temperature  incident  to  its  employment  as  a  dressing,  are  favorable  to  the 
process  of  adhesive  inflammation.  It  is  a  mode  of  dressing  very  commonly 
employed,  and  often  in  a  somewhat  perfunctory  way,  but  it  may  be  questioned 
if  the  application  of  cold  as  a  preventive  of  excessive  vascular  action  to  a 
wound  just  closed  is  the  wisest  course  to  pursue.  Prevention  is  an  excellent 
measure,  but  here  it  might  possibly  prove  officious,  as  excessive  action  may 
not  occur,  and  more  really  useful  measures  may  be  excluded  by  its  use.  Ab- 
solute quietude  for  the  part — a  stump  after  an  amputation,  for  example — and 
an  equable  temperature,  with  gentle  uniform  pressure  accompanied  by  anti- 
septic precautions,  will  more  certainly  second  iSTature's  efforts  to  bring  about 
prompt  union  without  complication,  which  is  the  result  desired. 

Cold  applications  may,  under  some  circumstances,  prove  positively  injurious. 
vol.  i. — 10 


146  INFLAMMATION. 

The  use  of  an  ice  bag,  by  producing  excessive  vascular  contraction,  has  caused 
gangrene  of  the  edges  of  a  wound.  It  is  to  be  observed,  also,  that  after  a 
cold  application  has  been  removed  from  a  part,  more  or  less  vascular  reaction 
always  follows,  in  the  way  of  afflux  and  increase  of  heat,  Although  the  fact 
has  not  often  been  noticed,  it  is  hard  to  believe  that  parts  frozen  by  ether-spray , 
or  freezing  mixtures,  to  produce  anaesthesia,  are  not  more  or  less  impaired  in 
their  vitality. 

On  the  other  hand,  the  use  of  an  ice-cap  to  the  shaved  head  has  a  positive 
value  in  the  cerebro-meningitis  which  so  often  complicates  wounds  of  this 
region.  Esmarch  especially  praises  cold  in  injuries  of  joints  as  preventing  and 
controlling  intense  vascular  excitement.  The  use  of  crushed  ice  in  a  bladder, 
which  can  be  moulded  to  the  part,  is  a  favorite  remedy  for  inflamed  hemor- 
rhoids in  the  early  stage.  In  the  excessive  temperature  of  the  body  in  fever, 
the  cold  bath  and  the  cold  pack  are  remedies  of  undoubted  power  in  dimin- 
ishing the  danger  of  fatal  injury  to  vital  organs  from  the  overheated  blood. 

Heat  and  Moisture. — Dry  heat  is  well  known  for  its  efficiency  in  calming 
pain;  and  heat,  with  moisture,  in  the  form  of  a  poultice,  constitutes,  perhaps, 
the  local  remedy  sanctioned  by  most  general  use  for  the  relief  of  the  pain  and 
tensive  heat  of  a  local  inflammation.  Its  soothing  and  relaxing  effect  upon 
the  inflamed  part  is  the  reverse  of  the  astringent,  although  sedative,  action 
of  cold.  The  latter  finds  the  indication  for  its  use  in  the  very  earliest  evi- 
dences of  excess  in  vascular  action  that  succeed  an  injury,  and  here  it  con- 
stringes  the  capillaries  of  the  inflaming  part,  and  promotes  a  disposition  to 
return  to  a  normal  condition — in  other  words,  to  a  termination  by  resolution. 
On  the  other  hand,  the  influence  of  moist  heat  upon  the  tissues  of  an  inflam- 
ing part  is  distinctly  relaxing,  and,  therefore,  tends  rather  to  promote  exuda- 
tion, if  not  suppuration.  This  tendency  of  a  poultice  or  warm  fomentation 
to  favor  suppuration,  is  an  article  of  popular  belief,  but  there  is  no  absolute 
certainty  of  its  truth.  Habitually,  in  practice,  cold  applications  are  aban- 
doned as  soon  as  resolution  seems  unattainable,  and  poultices  are  substituted, 
on  the  assumption  that  suppuration  is  the  next  best  result  to  be  hoped  for. 
At  this  juncture  compression  may  be  possibly  introduced,  tentatively,  as  an 
alternative,  if  the  influence  of  the  poultice  in  causing  suppuration  is  feared. 
After  this,  if  the  pain  continue,  the  use  of  the  poultice  is  justified. 

Where  pain  is  a  prominent  symptom,  it  is  an  excellent  plan  to  sprinkle  the 
surface  of  a  poultice  with  laudanum,  or  to  anoint  the  inflamed  part,  when 
the  skin  is  unbroken,  with  the  ointment  of  stramonium  or  any  other  narco- 
tic. In  acute  and  painful  inflammations  of  the  testicle,  the  tobacco  poultice 
has  long  been  in  use  at  the  New  York  Hospital ;  it  is  very  effective  in  epi- 
didymitis. It  is  a  common  practice  in  France  and  Germany,  sanctioned  by 
the  authority  of  Velpeau  and  Billroth,  to  cover  an  inflamed  surface  with 
mercurial  ointment  before  applying  a  poultice.  This  is  based  on  the  wide- 
spread belief,  founded  upon  its  singular  efficiency  in  syphilitic  inflammations, 
that  this  drug  has  a  certain  power  in  mitigating  the  intensityof  the  inflam- 
matory act,  and  in  rendering  exudations  more  readily  absorbable.  There  is 
no  positive  evidence  that  mercury  possesses  this  power  except  in  syphilis. 

The  materials  which  have  been  found  to  possess  the  best  qualities  as  poul- 
tices,  aii'  freshly  ground  flaxseed  and  slippery  elm  bark.  The  consistence  of 
a  poultice  and  its  emollient  and  unirritating  character  render  it  capable  of 
being  moulded  in  contact  with  the  irregularities  of  surface  of  open  and 
granulating  wounds.  The  addition  of  vaseline,  or  of  boracic  acid,  or  of  a 
weak  solution  of  carbolic  acid,  will  prevent  fermentation  in  the  poultice,  and 
counteract  putrefaction  in  the  wound.     The  liberal  application  of  the  balsam 


TREATMENT    OF    INFLAMMATION.  147 

of  Peru,  which  is  a  good  antiseptic,  to  the  surface  of  a  contused  wound  before 
applying  a  poultice,  is  a  favorite  practice. 

Poultices  have  been  criticized  as  uncleanly,  particularly  by  Listen,  who 
strongly  advocated  "water  dressing"  as  a  substitute.  In  its  most  common 
form,  water  dressing  consists  of  a  cloth  saturated  with  water  or  an}T  medi- 
cated solution,  and  then  covered  in  by  oiled  silk  or  some  impermeable  tissue 
to  prevent  evaporation  and  drying.  Water  dressing  is  a  very  useful  applica- 
tion for  inflamed  surfaces.  When  the  latter  are  irregular,  absorbent  cotton 
may  be  applied  more  accurately  in  contact  with  them,  and  then  saturated 
with  fluid,  medicated  or  otherwise,  and  covered  in.  A  solution  of  boracic 
acid  or  biborate  of  sodium  is  an  excellent  medication.  A  bandage  is  more 
conveniently  applied  over  a  water  dressing  than  over  a  poultice.  The  latter, 
however,  has  by  no  means  lost  its  place  in  either  professional  or  popular 
confidence. 

It  is  to  be  remarked  that  poultices  are  often  continued  unwisely  long  after 
the  indications  for  their  use  have  ceased.  Their  prolonged  employment 
begets  an  unhealthy  relaxation  of  the  tissues  thus  subjected  to  too  much 
maceration,  by  which  the  cuticle  of  neighboring  sound  integument  is  liable 
to  become  water-soaked  and  detached.  In  opten  wounds  thus  injudiciously 
treated,  granulations  tend  to  become  exuberant,  pale,  and  flabby,  and  cicatri- 
zation may  be  indefinitely  deferred.  Under  these  circumstances  a  change  to 
dry  dressing  with  moderate  compression  is  often  followed  by  benefit. 

A  very  useful  and  beneficial  mode  of  applying  heat  and  moisture  is  by 
means  of  the  local  warm  bath.  In  renewing  dressings  of  open  wounds  of 
the  extremities,  it  is  constantly  indicated.  A  tin  vessel  of  proper  size  and 
shape  to  receive  the  forearm  when  the  elbow  is  flexed,  in  which  it  may  be 
subjected  to  prolonged  immersion  without  inconvenience  or  fatigue  on  the 
part  of  the  patient,  who  occupies  a  sitting  position,  is  of  great  value  ;  for  ex- 
ample, after  incision  and  a  first  dressing  by  compression  or  poultice  in  spread- 
ing inflammation  extending  up  the  forearm  from  an  injured  hand,  a  local 
bath  of  an  hour  or  two  before  the  surgeon's  visit  will  add  greatly  to  the  pa- 
tient's comfort  and  very  much  facilitate  the  subsequent  dressing.  Granula- 
tions have  been  found  to  form  rapidly  and  grow  well  in  a  part  submerged  in 
tepid  water ;  and  for  restoring  an  unhealthy  wound  or  ulcer  to  a  health}' 
condition,  there  is  no  better  resource  than  a  prolonged  bath  rendered  antisep- 
tic by  carbolic  acid  or  some  other  substance  possessing  similar  properties.  A 
thorough  application  of  eight  per  cent,  solution  of  chloride  of  zinc,  followed 
by  a  prolonged  local  warm  bath,  has  proved  very  effective  in  the  disinfection 
of  foul  and  unhealthy  parts.  As  to  the  use  of  the  general  warm  bath,  its 
advisability  must  be  determined  by  the  condition  and  circumstances  of  the 
patient. 

Compression. — Compression,  if  applied  evenly,  continuously,  and  not  too 
forcibly,  is  a  very  valuable  agent  in  the  treatment  of  many  of  the  phases  of 
the  inflammatory  condition.  It  is  capable  of  acting  beneficially  in  several 
different  ways  according  to  the  stage  of  the  process.  In  acute  inflammation, 
we  have  undoubtedly  the  power,  by  the  use  of  systematic  compression,  of 
restraining  the  tendency  to  over-distension  of  the  enlarging  capillaries,  and  of 
limiting  the  amount  of  exudation  ;  and  in  its  chronic  form,  a  wider  range  for 
application  of  the  remedy,  in  promoting  absorption.  But  the  use  of  this  power 
may  be  attended  by  pain,  and  no  inconsiderable  degree  of  danger.  Of  this  we 
have  clinical  evidence  in  the  cases  recorded  in  which  the  testicle  has  sloughed 
after  the  application  of  strips  of  adhesive  plaster  to  control  acute  epididymi- 
tis; and  we  may  assume  that  instances  in  which  this  misfortune  has  occurred 
have  been  left  unrecorded.     This  mode  of  treatment  of  inflammations  of  the 


148  INFLAMMATION. 

testicle  by  strapping,  was  at  one  time  largely  in  vogue,  but  it  lias  fallen 
greatly  into  disuse.  The  bad  consequences  which  so  often  follow  tight 
bandaging  belong,  also,  to  the  category  of  ill  effects  which  injudicious  com- 
pression may  cause. 

It  is  in  the  later  phases  of  inflammation,  that  compression  may  be  em- 
ployed with  the  greatest  advantage.  To  aid  resolution  by  increased  support 
to  the  walls  of  vessels  which  have  been  over-distended,  and  are  now  tending 
to  recontract ;  to  favor  the  absorption  of  liquid  and  solid  materials  which  * 
have  accumulated  in  the  peri-vascular  connective  tissue  by  exudation ;  and  in 
this  way  to  prevent,  under  many  circumstances,  the  formation  of  pus  by  ex- 
pediting a  return  of  the  parts  to  a  normal  condition,  are  the  results  which 
may  be  accomplished  by  judicious  compression.  To  keep  healthy  granulat- 
ing surfaces  in  contact  so. as  to  secure  their  adhesion;  to  support  and  gently 
press  together  the  walls  of  abscesses  after  evacuation,  in  view  of  a  similar 
result ;  and  to  restrain  serous  exudation  in  parts  weakened  by  inflammation, 
are  additional  illustrations  of  its  utility. 

But  it  is  in  chronic  inflammation,  and  in  facilitating  the  absorption  of  its 
products  in  the  way  of  induration  and  accumulated  neoplastic  formation,  that 
the  employment  of  compression  is,  perhaps,  most  useful.  An  example  of  the 
benefit  to  be  derived  from  systematic  compression  is  afforded  by  the  treat- 
ment of  an  indolent  ulcer  by  strapping — after  the  method  known  as  Bayn- 
ton's,  at  one  time  in  great  repute — by  which  the  surrounding  embankment 
of  induration  is  effaced  by  absorption,  and  its  obstructed  circulation  restored. 
Another  is  seen  in  the  shrinking  of  glandular  swellings  which  have  resulted 
from  chronic  inflammation.  The  mechanism  of  the  cure  in  these  cases  is 
explained,  in  part,  by  the  restored  action  of  the  lymphatics  effected  by  the 
removal  of  the  pressure  caused  by  the  obstructive  new  formation.  It  may  be 
remarked  that  the  power  of  iodine  applied  locally  over  glandular  swellings, 
in  promoting  absorption,  although  highly  sanctioned,  is  probably  exagge- 
rated, and  notably  inferior  to  that  exercised  by  skilfully  applied  pressure. 
The  remarkable  effect  of  this  drug  in  dissipating  the  gummatous  .swellings 
of  syphilis  has  acquired  for  it  more  reputation  than  it  deserves,  as  regards 
swellings  of  a  different  nature. 

Compression,  as  employed  in  the  treatment  of  inflammation,  may  be 
effected  by  different  methods,  each  of  which  has  its  advantages.  The  ordinary 
roller  bandage  of  undressed  cotton-cloth  is  very  useful  in  skilful  hands,  and 
applicable,  extemporaneously,  under  man}'  circumstances.  By  availing  him- 
self of  the  elasticity  of  cotton-wool,  and  placing  two  or  more  layers  of  ordi- 
nary cotton-batting  upon  the  part  to  be  compressed,  the  surgeon  may  apply  a 
bandage  tightly  over  the  cotton  without  fear  of  pausing  any  irregular  con- 
striction ;  and  lie  will  also  secure  by  this  device  the  additional  advantage  of 
keeping  the  part  at  an  uniform  temperature.  These  are  points  of  decided 
value,  for  an  even  soft  elastic  pressure,  with  warmth  unvarying  in  degree,  are 
most  useful  conditions  in  the  treatment  of  inflammation. 

This  method  of  dressing,  with  cotton,  constitutes  the  "appareil  ouati"  of 
Alphonse  Guerin,  who  has  employed  it  largely  at  the  Hotel  Dieu,  at  Paris, 
claiming  for  if,  when  applied  over  recently  closed  wounds,  absolute  antiseptic 
properties.  It  is  well  known  that  air  is  deprived  of  all  dust,  and,  therefore, 
<<!'  possible  aerial  germs,  by  being  filtered  through  cotton-wool.  Tyndall  has 
shown  thai  l!n'  most  readily  putrescible  fluid  in  a  test-tube,  the  mouth  of 
which  is  plugged  by  cotton-wool,  will  remain  free  from  putrefactive  change 
indefinitely.  This  quality  in  cotton  gives  it  additional  value  as  a  material 
for  surgical  dressings.  A  purl  from  our  present  purpose,  the  dressing  of  cot- 
ton wadding  is  ;i  -I  useful  resource  in  the  treatment  of  fractures,  where  it 

aids  in  securing  pressure  enough  to  effect  immobility  without  danger;  and  in 


TREATMENT    OF    INFLAMMATION.  149 

military  surgery,  where  it  is  invaluable  as  a  protective  against  the  pain  and 
danger  incurred  in  transportation  of  the  wounded. 

A  bandage  of  flannel  is  more  elastic,  and  less  liable  to  produce  irregular 
constriction  of  a  limb  when  applied  by  unskilful  hands,  as  by  those  of  a 
patient.  This  is  still  more  true  of  the  bandage  of  caoutchouc,  which  has 
been  employed  so  successfully  by  Dr.  Martin,  of  Boston,  especially  in  the  cure 
of  varicose  ulcers  of  the  legs.  A  poor  man  may  be  cured  by  the  use  of  tins 
bandage  without  confinement  from  his  daily  labor,  applying  it  without  diffi- 
cnlty  every  morning  with  his  own  hands.  It  is  undoubtedly  superior  to  the 
elastic  stocking,  which  can  rarely  be  made  so  as  to  fit  evenly  at  all  points. 
The  absorption  of  tumors  has  even  been  effected  by  its  use. 

An  ingenious  and  effective  mode  of  making  pressure  upon  a  limited  area, 
as  upon  an  inguinal  gland,  or  a  chronic  ulcer  of  the  leg,  is  by  compressed 
sponge.  A  fine,  dry  sponge  which  has  been  thoroughly  flattened  by  being 
placed  for  a  few  hours  between  two  unyielding  surfaces  under  a  weight,  may 
be  applied  over  a  chronically  enlarged  inguinal  gland,  or  an  indurated  sinus, 
and  confined  in  its  place  by  a  spica  bandage ;  if  some  tepid  water  be  now  al- 
lowed to  trickle  down  so  as  to  moisten  the  sponge,  it  will  exert  a  perfectly 
safe  and  painless  but  effective. pressure  upon  the  part  as  it  returns  to  its  origi- 
nal size.  A  disk  of  compressed  sponge  applied  in  this  manner  over  a  chronic 
ulcer  with  elevated  edges  and  depressed  centre,  will  moisten  itself  by  the 
discharge  provoked  by  its  contact  with  the  face  of  the  ulcer,  and  entirely 
remove  the  unhealthy  features  of  the  sore.  In  the  absence  of  pain,  this  dress- 
ing may  be  left  undisturbed  for  forty-eight  hours,  and  even  in  this  short  time 
an  apparently  incurable  chronic  sore  has  been  found  converted  into  a  healthy 
granulating  surface,  which  the  subsequent  use  of  the  caoutchouc  bandage  has 
rapidly  conducted  to  cicatrization. 

Pressure  may  be  conveniently  applied  in  the  groin,  in  some  cases,  by  means 
of  a  truss,  or,  if  the  patient  can  be  confined  to  his  back,  by  the  pressure  of  a 
bag  of  shot. 

Blood-letting. — Before  the  middle  of  the  present  century,  blood-letting  in 
some  form  was  universally  regarded  as  the  remedy  of  paramount  importance 
in  combating  inflammation.  This  condition  was  regarded  as  a  disease  with 
pain,  heat,  and  increased  vascular  action  as  its  prominent  symptoms ;  and  be- 
cause these  were  almost  certain  to  be  favorably  modified,  at  least  for  the  time, 
by  the  abstraction  of  blood,  this  measure  became  the  great  antiphlogistic 
remedy.  It  is  certainly  a  remedy  of  power,  and  as  certainly  its  power  was 
abused,  and  its  use  carried  to  excess  and  misapplied;  hence  the  revulsion 
against  blood-letting  which  commenced  during  the  last  generation.  This 
was  aided  by  the  rapid  progress  of  pathology,  after  it  had  been  placed  upon 
an  anatomical  basis  by  the  anatomical  school.  It  had  become  evident  that 
many  diseases,  before  regarded  as  inflammatory,  were  entirely  dependent  upon 
other  causes  than  those  which  constituted  the  inflammatory  condition,  and 
that  they  were  not  amenable  to  blood-letting;  that,  on  the  contrary,  they  were 
injured  by  it.  The  revulsion  against  bleeding,  like  all  fluctuations  in  human 
opinion,  has  been  carried  to  excess,  and  protests  have  been  made,  as  by  Sir 
James  Paget,  against  its  abandonment  to  such  an  exclusive  degree. 

In  our  country,  there  are  climatic  influences  which  have  an  adverse  bearing 
upon  the  use  of  depletion  as  a  remedy.  The  greater  dryness  of  the  atmo- 
sphere, and  the  extremes  of  temperature  which  characterize  our  climate,  ex- 
ercise a  stimulating  influence  upon  the  nervous  system,  and  the  nervous  cen- 
tres are  liable  to  disproportionate  wear  and  tear.  The  conditions  and  sur- 
roundings of  modern  life,  and  the  habitual  use  of  more  stimulating  food  and 
drink,  tend  to  promote  nervous  exhaustion.     The  liability  to  extreme  cold  hi 


150  INFLAMMATION. 

winter  has  led  to  the  general  use  of  the  hot  air  furnace,  the  highly  heated 
air  containing,  almost  inevitably,  more  or  less  of  the  subtle  carbonic  oxide 
gas  which  finds  its  way  through  the  cast-iron  fire-box  of  the  furnace.  This 
gas,  according  to  Bernard,  acts  directly  upon  the  red  corpuscles  of  the  blood, 
destroying  them  fatally  by  simple  contact,  and  producing,  when  habitually 
respired,  an  anaemic  aspect.1  It  is  not  impossible  that  more  red  globules  are 
destroyed,  in  the  aggregate,  in  this  way,  than  by  the  frequent  blood-lettings 
practised  by  our  ancestors.  Red  blood  corpuscles  are  reproduced  in  the  or- 
ganism with  wonderful  rapidity,  and  this  explains  the  strange  tolerance  of  so 
serious  a  measure  as  the  abstraction  of  large  quantities  of  blood;  but  these 
reproductions  must  involve  an  expenditure  of  life-force  which  it  would  be 
better  to  economize.  The  circumstances  of  the  rapid  growth  of  cities,  and 
of  the  diminishing  tendency  to  out-door  life,  through  desire  to  avoid  exposure 
to  extreme  heat  or  cold,  are  not  without  their  influence  in  depriving  our 
population  of  their  supply  of  oxygen. 

At  the  present  time,  in  our  country,  general  bleeding  is  rarety  employed. 
The  aggregate  sense  of  the  profession,  influenced,  possibly,  by  considerations 
similar  to  those  just  advanced,  seems  to  be  adverse  to  its  use  as  a  remedy. 
The  surgeon  stands  ready  to  bleed  ad  deliquium  to  prevent  impending  suftb^ 
cation  from  hemorrhage  in  a  wound  of  the  lung,  resorting  to  the  remedy  as 
a  hemostatic;  but  he  would  not  bleed,  subsequently,  to  prevent  or  control 
inflammation  of  the  lung,  because  experience  in  military  surgery  has  taught 
him  that  this  rarely  transcends  the  constructive  stage,  and  that  the  greater 
danger  in  wounds  of  this  organ  is  threatened  from  suppuration  of  the  pleura, 
which  no  amount  of  depletion  would  prevent.  Bleeding  from  the  arm,  by 
promptly  lowering  the  action  of  the  heart,  might  be  of  service  in  acute  trau- 
matic cerebro-meningitis,  in  view  of  the  great  danger  of  intra-cranial  pus 
formation,  and  the  soft  texture  and  great  vascularity  of  the  encephalon  ;'  but 
in  surgical  fevers  with  a  high  temperature  from  blood-poisoning,  this  measure 
has  proved  of  no  avail. 

On  the  other  hand,  the  local  abstraction  of  blood  by  means  of  leeches,  cups, 
and  other  devices,  is  of  great  service  in  moderating  vascular  action,  and  in 
warding  off  destructive  inflammatory  symptoms.  This  effect  is  noticeable  in 
inflammation  of  the  eye  after  the  remedy  has  been  applied  on  the  temple. 
In  chronic  inflammation  of  the  knee-joint,  cupping  relieves  pain  and  spas- 
modic twitching  of  the  muscles ;  but  its  action  is  only  temporary.  After  a 
recent  wound  or  injury  of  the  knee-joint  threatening  disorganization,  a  gen- 
erous application  of  leeches  in  conjunction  with  immobility,  the  leeches  being 
repeated  promptly  and  heroically  as  often  as  the  pain  returns,  is  competent  to 
restrain  the  inflammation  within  the  bounds  of  repair,  and  thus,  possibly,  to 
save  the  articulation.  The  power  of  local  bleeding  to  relieve  h}'pera?mia  is 
well  seen  in  the  prompt  cessation  of  the  intolerable  pain  of  epididymitis  in 
the  condition  known  as  strangulation,  by  the  application  of  leeches  over  the 
cord.  Here  the  over-distended  veins  of  the  cord  are  obstructed  by  the  un- 
\  ielding  edges  of  the  external  abdominal  ring,  with  consequent  stagnation  of 
circulation,  and  pressure  upon  the  nerves  going  to  the  testicle. 

These  examples  will  serve  to  show  the  advantages  which  may  be  gained 
from  local  depletion.     Repetition  of  the  remedy  is  likely  to  be  required  to 

1  Describing  the  blood  of  a  person  who  has  been  poisoned  by  carbonic  oxide,  as  by  the  fnmes 
of  burning  charcoal,  lie  snys  :  "IT  examined,  it  will  bo  found  to  have  lost  its  power  of  absorbing 
oxygen.  It  is  the  red  blood  globule  especially  which  is  altered  ;  its  function  as  an  oxygen  carrier  is  • 
abolished.  ( Ince  exposed  to  the  contact  of  t  lie  carbonic  oxide,  a  chemical  change  instantaneously 
takes  place  in  its  substance,  ami  iii  consequence  of  this  change  it  is  thenceforward  indifferent  to 
i.  It  becomes  .'it  once  an  inert  body,  a  simple  mineral  atom,  a  grain  of  sand.  Chemically, 
tin'  oxide  of  carbon  has  driven  out  the  oxygen  from  its  combination  with  the  hemoglobuline  of 
t  hr  red  globule,  and  takes  its  place,  vol  nine  for  volume."  (Lecons  sur  la  chaleur  animale,  p.  li)ij.) 


TREATMENT  OF  INFLAMMATION.  151 

counteract  a  tendency  to  renewed  afflux,  and  thus  to  socure  all  the  benefit  it 
is  capable  of  conferring. 

Leeches  are  not  properly  applied  to  the  scrotum,  nor  to  the  front  of  the 
neck,  nor  to  any  part  where  pressure  may  not  be  readily  applied  in  the  event 
of  protracted  oozing  of  blood  after  they  have  dropped  ;  nor  is  their  applica- 
tion judicious,  as  a  rule,  in  the  inflammations  of  children,  in  view  of  their 
liability  to  subsequent  hemorrhage,  and  of  the  fact  that  loss  of  blood  is  badly 
borne  in  early  life. 

Incisions. — Incision  in  the  treatment  of  inflammation  is  often  a  remedy  of 
the  first  importance.  It  is  required  to  meet  two  distinct  indications:  (1)  as 
a  means  of  relieving  tension,  and,  with  it,  pain ;  and  (2)  for  the  purpose  of 
evacuating  pus,  or  allowing  the  escape  of  dead  tissues. 

Tension  of  the  tissues,  however  produced,  directly  tends  to  provoke  inflam- 
mation, and  also  to  increase  its  destructiveness — as  where  the  opening  of  an 
acute  abscess  is  delayed.  The  redness  and  heat  of  skin  that  often  occur  in 
swelled  legs,  in  dropsy,  form  another  example.  Tension  is,  therefore,  one  of  the 
causes  of  inflammation  ;  and  incision  is  the  remedy  required  in  most  cases  for 
its  relief.  It  is  not  unfrequently  indicated  for  this  purpose,  let  it  be  noticed, 
even  where  pus  is  not  suspected  to  exist ;  and  it  is  employed  simply  as  a  pre- 
ventive of  suppuration,  and  especially  of  ulceration.  Superficial  incisions 
have  been  advocated  to  relieve  the  tension  of  the  skin  in  simple  cutaneous 
erysipelas ;  but  in  such  a  self-limiting  disease  they  are  rarely  required  to 
meet  this  indication,  although  sometimes  necessary  to  give  issue  to  pus  which 
may  form  at  points  where  the  connective  tissue  is  lax,  as  in  the  eyelids. 

When  the  presence  of  pus  is  suspected,  but  not  rendered  certain  by  fluctu- 
ation, then  deeper  incision,  with  the  double  view  of  relieving  tension  and  also 
of  liberating  pus,  if  present,  is  very  often  a  judicious  measure.  When  incision 
involves  only  the  thickness  of  the  skin,  it  is  a  very  simple  proceeding  ;  but 
when  pus  is  to  be  sought  for  deeply,  it  becomes  an  operation  of  some  delicacy, 
and  the  knife  is  to  be  supplemented  by  the  director  and  finger,  in  exploration, 
in  order  to  avoid  possible  danger  to  arteries  and  nerves. 

For  the  double  purpose  of  relieving  tension  and  evacuating  pus,  very  long 
incisions  have  been  advocated  by  high  authority  in  phlegmonous  erysipelas ; 
but  here,  and  under  all  similar  circumstances  where  this  remedy  is  indicated, 
a  number  of  short  incisions,  according  to  the  necessity  of  the  case,  are  to  be 
preferred.  Long  incisions  are  but  little  more  effective,  and  they  require  a 
much  longer  time  for  healing ;  they  are,  also,  less  easily  manageable  where  it 
is  desirable  to  avoid  loss  of  blood.  This  may  be  a  point  of  importance  in 
phlegmonous  erysipelas,  in  which  depletion  is  illy  borne.  But  by  adopting 
the  plan  of  making  short  incisions  completely  through  the  skin  in  rapid 
succession,  and  having  an  assistant  ready  to  crowd  a  fragment  of  sponge  or  a 
wad  of  absorbent  cotton  into  each  instantly,  and  to  make  temporary  pressure, 
loss  of  blood  can  be  rendered  very  trivial.  Where  the  integument  is  thick- 
ened, brawny,  and  intensely  congested,  there  may  be  a  free  gush  of  blood 
from  the  distended  surface  vessels  for  the  moment,  but  it  subsides  at  once  as 
the  parts  contract.  There  is  no  one  of  the  minor  operations  of  surgery  more 
immediately  beneficial  than  this.  In  phlegmonous  erysipelas,  and  in  all  the 
spreading  and  diffuse  inflammations,  incision  is  the  remedy  of  paramount 
utility,  because  death  of  subcutaneous  tissue  occurs  early — sometimes,  indeed, 
as  the  initial  lesion  of  the  case — and,  until  an  avenue  of  escape  is  provided 
for  the  sloughs,  pus  formation  tends  to  advance  progressively  beneath  the 
skin,  where  it  is  liable  to  be  attended  by  indefinite  destruction  of  tissue. 
When  timely  and  sufficiently  ample  openings  have  been  provided,  the  de- 
structive process  is  in  most  instances  arrested  at  once.     Incisions  save  the 


152  INFLAMMATION. 

integument  which  would  otherwise  be  destroyed  by  the  spontaneous  forma- 
tion of  gangrenous  patches — a  result  which,  without  this  remedy,  is  almost 
inevitable.  In  this  way,  indeed,  both  the  necessity  and  the  great  value  of 
early,  free,  and  bold  incision  is  demonstrated. 

In  acute  abscess,  also,  incisions  should  be  made  both  early  and  freely.  In 
an  abscess  of  any  size,  the  incision  should  be  always  made  large  enough  to 
admit  the  forefinger  for  exploration.  There  is  nothing  more  unsurgical  than 
an  insufficient  puncture  for  the  evacuation  of  pus.  An  opening  in  a  position 
which  is  not  fully  and  entirely  depending,  unless  such  a  position  cannot  be 
secured,  is  equally  reprehensible.  Both  of  these  common  errors  interfere 
with  the  promptly  curative  effect  of  a  good  remedy;  they  invite  a  continu- 
ance of  the  inflammatory  condition,  and  the  formation  of  a  sinus.  A  clean 
incision  through  the  skin  is  easily  and  certainly  repaired,  and  cannot  cause 
untoward  bleeding  unless  the  patient  be  a  victim  of  the  hemorrhagic  diathesis, 
which  can  be  ascertained  beforehand  by  inquiry  as  to  previous  experiences, 
and  then  a  twisted  suture  may  be  required.  The  extreme  probability  that, 
in  acute  abscess,  there  is  absolute  necessity  for  the  evacuation  of  something 
of  the  nature  of  a  quasi  foreign  body  by  which  the  collection  has  been  pro- 
voked, renders  delay  in  opening  unwise  after  fluctuation  has  become  recog- 
nizable ;  under  these  circumstances,  delay  involves  a  further  continuance  of 
the  process  of  destructive  inflammation,  and  is  rarely  justifiable. 

On  the  other  hand,  in  chronic  and  cold  abscess,  incision  may  be  very  prop- 
erly delayed,  or  substituted  by  aspiration,  or  by  a  valvular  puncture  with  a 
trocar,  which  may  be  promptly  closed. 

Drainage. — In  dressing  an  open  wound  of  any  size  for  primary  union,  it  is 
the  surgeon's  duty  to  provide  a  readily  available  outlet  for  any  fluids  that 
may  collect  within  it.  Otherwise  these  would  separate  the  opposed  surfaces 
as  they  accumulate,  and  surely  defeat  the  object  of  the  dressing. 

The  materials  liable  to  collect  in  a  closed  wound  are:  (1)  excess  of  thin 
liquid  exudation,  containing  more  or  less  blood  clot  in  solution,  giving  the 
fluid  a  certain  resemblance  to  blood;  (2)  blood,  which,  in  most  cases,  coagu- 
lates ;  (3)  oil,  when  fatty  tissue  has  been  divided  to  any  extent ;  (4)  after  an 
interval,  and  some  fever,  pus. 

These  obstacles  to  prompt  union  by  the  constructive  process  may  all  be  ob- 
viated with  a  good  deal  of  certainty  by  the  judicious  emplo}Tment  of  drains 
as  a  part  of  the  dressing  of  the  wound.  In  their  absence,  symptoms  of  de- 
structive inflammation  will  almost  inevitably  follow,  e.  g.,  pain,  throbbing, 
heat,  tension,  and  swelling,  with  more  or  less  extensive  surface  redness.  With 
these,  there  is  constitutional  disturbance  and  fever,  and,  sooner  or  later,  ab- 
scess. Drainage  is,  therefore,  entitled  to  a  place  amongst  the  remedies  in 
inflammation;  and,  if  employed  with  tact  and  judgment,  it  will  prove  in  most 
cases  a  most  valuable  resource  both  as  a  curative  and  as  a  preventive  measure. 

The  proper  mode  of  effecting  the  drainage  of  a  wound  is  to  place  within  it 
certain  materials,  such  as  caoutchouc  tubing  with  lateral  openings,  strands  of 
horsehair,  of  hempen  thread,  or  silk — preferably  waxed — or  any  other  unir- 
ritating  material  capable  of  carrying  off  fluids  by  capillary  conduction.  These 
materials  for  draining  should  be  thoroughly  cleansed  by  immersion  in  a  solu- 
tion of  carbolic  acid  or  some  other  disinfecting  preparation,  before  being 
placed  in  a  wound;  and  they  should  be  disposed, as  regards  size  and  number, 
according  to  its  shape  and  extent,  as  detailed  in  other  articles. 

The  selection  of  a  proper  position  for  a  depending  outlet  in  opening  an  ab- 

.  or  in  securing  a  direct  avenue  lor  the  escape  of  pus  wherever  it  tends  to 

accumulate — by  incision  or  puncture,  and  the  introduction  of  a  drainage  tube 

— and  such  alteration  in  the  position  of  the  part  as  may  be  required  to  insure 


TREATMENT    OF    INFLAMMATION.  153 

its  efficient  action  in  preventing  re-accumulation  of  fluid  in  a  granulating 
cavity,  will  furnish  an  example  of  drainage  as  a  remedy  for  inflammation ; 
for  such  a  measure  positively  removes  impediments  to  repair,  and  prevents 
the  indefinite  continuance  of  pus  formation  and  other  destructive  symptoms. 
Experience  teaches  us  by  constant  examples — in  compound  fracture  as  a  very 
common  one — how  by  a  judicious  change  in  position,  say  by  suspending  a 
limb,  and  by  well  placed  incisions  to  receive  drainage  tubes,  and  thus  to  keep 
purulent  cavities  empty  and  to  prevent  pus  from  burrowing,  pain  and  fever 
are  relieved,  redness  and  swelling  disappear,  and  repair  by  healthy  granula- 
tion and  final  cicatrization  is  secured. 

Revulsion  and  Counter-Irritation. — Revulsion,  or  derivation,  is  effected 
by  exciting  an  afflux  of  blood  to  another  locality  in  more  or  less  immediate 
proximity  to  an  existing  inflammatory  focus,  and  thus  drawing  the  blood 
away  from  the  latter,  so  as  to  affect  its  condition  favorably.  This  remedy  for 
inflammation  is  also  called  counter-irritation,  and  it  might  with  equal  propriety 
be  described  as  substitution  ;  for  it  consists  in  artificially  creating  a  controllable 
inflammation,  with  the  object  of  cutting  oft*  the  vascular  supply — as  by  leech- 
ing, which  is  revulsive  as  well  as  depleting — from  another  inflammatory  con- 
dition which  is  less  controllable. 

The  means  employed  for  producing  revulsion  are  various:  blisters,  setons, 
issues,  the  moxa  and  other  forms  of  the  actual  cautery,  are  all  available,  and 
more  or  less  useful.  They  are  mainly  applicable  to  the  chronic  forms  of  in- 
flammation, in  which  the  more  philosophical  treatment  by  detection  or  re- 
moval of  the  cause  which  is  keeping  up  the  condition  is  not  available. 

As  an  exception  to  this  latter  statement,  great  virtue  has  been  claimed  for 
the  application  of  a  large  blister  over  the  chest,  in  averting  traumatic  pleurisy. 
Vesication  has  also  been  much  advocated  in  chronic  diseases  of  joints,  and 
blisters  are  generally  applied,  of  full  size,  alternately,  on  opposite  sides  of  the 
articulation.  Sometimes,  however,  smaller  blisters  are  preferred,  and  they 
are  rendered  less  transitory  in  their  effects  by  being  prevented  from  healing, 
and  forced  to  suppurate,  by  a  succession  of  irritating  applications,  thus  con- 
verting the  blister  into  a  permanent  issue.  Blistering  behind  the  ear  by 
means  of  vesicating  collodion  is  a  favorite  revulsive  in  eye  inflammations. 
Blistering  the  perineum  has  proved  serviceable  in  chronic  gleet  and  in  certain 
prostatic  affections  of  early  manhood. 

The  older  surgeons  attached  great  value  to  setons  and  issues  in  joint  dis- 
eases. It  is  not  many  years  since  the  insertion  of  a  loop  of  caoutchouc  behind 
the  great  trochanter,  as  a  permanent  seton,  with  cod-liver  oil  internally,  and 
life  in  the  open  air,  was  considered  the  best  treatment  for  hip-joint  disease; 
and  in  comparison  with  confinement  in  bed  in  the  horizontal  position,  pre- 
viously in  vogue,  it  was  certainly  a  great  improvement.  The  pea  issue  was 
a  favorite  remedy  of  Astley  Cooper  and  Valentine  Mott. 

Firing,  by  means  of  the  actual  cautery,  has  been  highly  praised  in  chronic 
disease  of  the  articulations.  The  modern  facilities  for  using  the  actual  cau- 
tery, and  the  employment  of  anaesthesia  during  its  application,  render  it  one 
of  the  most  available,  as  it  is  one  of  the  most  effective,  of  the  revulsives.  The 
moxa,  the  favorite  remedy  of  the  elder  Larrey,  the  fear  of  which  no  doubt , 
prevented  much  malingering  amongst  the  French  soldiers,  and  the  camphor 
moxa,  one  of  its  more  recent  substitutes,  have  given  place  to  other  forms  of 
actual  cautery.  A  dry  surface  eschar  produced  by  nitric  acid — the  least  pain- 
ful in  its  application  of  the  potential  caustics — and  left  without  any  dressing, 
constitutes  a  mild  but  not  inefficient  form  of  counter-irritation.  In  the  ordi- 
nary succession  of  remedies  in  chronic  inflammation,  the  different  forms  of 


154  INFLAMMATION. 

revulsion  and  counter-irritation  are  usually  preceded,  if  there  is  much  local 
heat,  by  the  application  of  leeches  or  cups. 

Derivation  by  Ligation  of  Main  Artery. — As  long  ago  as  1813,  it  was  pro- 
posed by  Dr.  Henry  U.  Onderdonk,  of  ISTew  York,  as  a  remedy  for  inflam- 
mation, to  cut  off  the  supply  of  blood  from  an  inflaming  part  by  ligating  its 
main  arterial  trunk.1  Instances  are  on  record  in  winch  this  measure  has 
been  followed  by  good  results.  The  femoral  artery  has  been  tied  after  a 
wound  of  the  knee  threatening  destructive  inflammation,  with  the  effect, 
apparently,  of  saving  the  joint,2  Though  recently  revived  and  ably  advo- 
cated by  Prof.  H.  F.  Campbell,  of  Augusta,  Georgia,  and  other  surgeons,  it  is 
not  probable  that  this  somewhat  hazardous  remedy  will  be  often  employed. 
Partial  arrest  of  the  flow  through  a  main  artery  by  a  compress  placed  under 
the  dressing,  has  been  employed  with  the  object  of  preventing  excessive  reac- 
tion after  an  operation. 

Diet  and  Cursing. — In  inflammation,  and  particular^  under  circumstances 
in  which  it  is  liable  to  assume  formidable  proportions,  the  diet  of  the  patient 
demands  intelligent  management  on  the  part  of  the  surgeon.  On  the  one 
hand  we  have  to  deal  with  digestive  organs  enfeebled  by  the  shock  of  injury, 
by  pain,  and  by  confinement  to  a  bed  with  unsavory  surroundings — and  pos- 
sibly weakened  by  disastrous  depletion,  or  by  exhausting  discharges ;  on  the 
other,  we  require  the  best  blood  which  the  patient's  organs  are  competent  to 
elaborate,  and  in  adequate  quantity,  in  order  to  carry  on  the  work  of  repair, 
or  replace  the  waste  of  fever. 

The  popular  idea  that  low  diet  is  necessary  in  the  treatment  of  inflamma- 
tion and  fever,  for  the  purpose  of  preventing  and  restraining  excessive  action, 
is  based  upon  the  same  fallacy  in  which  the  word  "  antiphlogistic"  took  its 
origin — a  term  which,  under  the  influence  of  the  prevailing  doctrines  of 
pathology,  has  lost  its  significance  and  is  falling  into  disuse.  The  facts  are, 
simply,  that  the  patient,  in  inflammation  or  fever,  should  be  provided  with 
the  most  nutritious  articles  of  food  that  his  stomach  is  able  to  digest,  and  in 
quantity,  and  at  intervals,  graded  in  accordance  with  its  power  to  dispose  of 
them.  Adequate  nutrition  is  to  be  sought  for,  and  danger  of  repletion  care- 
fully guarded  against.  It  is  a  judicious  plan,  in  a  serious  case,  to  prescribe 
the  hours  at  which  food  should  be  administered,  as  well  as  its  quantity,  in 
the  form  of  written  directions  placed  in  full  view  of  the  attendants  in  charge, 
and  to  see  that  they  are  systematically  enforced. 

It  Ls  the  popular  belief  that  the  medicines  prescribed  in  a  given  case  are 
more  important  to  the  patient  than  his  food  ;  whereas  the  reverse  is  generally 
true.  Systematic  and  judicious  feeding  is,  in  truth,  the  basis  on  which  suc- 
cessful treatment  is  founded.  In  the  language  of  Bernard,  the  anatomical 
elements  of  our  tissues,  and  the  organs  they  compose,  live  in  a  medium— an 
atmosphere,  so  to  speak — of  blood,  in  which  they  are  constantly  bathed,  and 
from  which  they  derive  all  their  sustenance.  It  is  a  paramount  necessity, 
therefore,  that  the  nutritive  qualities  of  this  all-important  fluid  should  be 
constantly  renewed  by  the  mode  which  Nature  has  ordained. 

There  are  many  articles  of  diet  usually  regarded  as  appropriate  food  for 
the  sick,  (lie  nutritious  qualities  of  which  are  very  much  overrated.  Arrow- 
root and  jelly,  for  example,  are  almost  worthless;  and  beef-tea,  as  usually  pre- 
pared,  is  useful  for  little  else  than  to  supply  blood  salts.     The  use  of  these 

1  Letter  to  Dr.  David  Ilosack,  published  in  the  American  Medical  and  Philosophical  Register, 
'  m    .  1813. 

8  See  a  paper  by  Dr.  David  L.  Rogers,  in  the  New  York  Medical  Journal,  vol.  iii.  p.  453,  1824; 
an  1,  also,  "Surgical  Essays,"  by  the  same  author,  1849. 


TREATMENT    OF   INFLAMMATION.  155 

and  similar  articles  of  sick  food  is  indicated  where  the  appetite  of  the  patient 
is  greater  than  his  power  of  digestion ;  they  are  momentarily  satisfying,  but 
innutritious. 

Milk)  as  a  rule,  is  the  most  valuable  of  all  articles  of  diet  in  sickness.  It 
is  the  best  vehicle  for  stimulus  in  the  form  of  spirit,  when  this  is  indicated, 
sheathing  it  like  an  emulsion  and  protecting  the  stomach  from  irritation.  It 
is  to  be  remembered  that  milk  coagulates  as  soon  as  it  is  swallowed,  and  is 
equivalent  to  solid  food.  The  addition  of  gelatine  renders  its  clot  less  solid, 
and  lime-water  or  mineral  waters  containing  lime  salts,  like  Seltzer  water, 
make  it  more  soft  and  digestible.  A  little  solid  food  that  can  be  chewed  and 
properly  insalivated  is  more  acceptable  to  the  stomach  than  a  uniformly  liquid 
diet.  As  to  digestibility,  sweet-bread,  if  not  fried,  ranks  high,  or  soft  boiled  egg 
with  bread  crumb,  and  beef  even  raw,  grated,  or  reduced  to  a  pulp  and  placed 
between  thin  slices  of  good  stale  buttered  bread,  are  examples  of  nutritious 
and  digestible  solid  food.  The  intervals  at  which  food  is  given  should  rarely 
exceed  two  hours,  with  one  longer  interval,  if  possible,  for  rest. 

As  for  stimulus,  if  it  is  administered  with  judgment,  alcohol  is  eminently 
useful,  both  as  a  cardiac  stimulus  and  as  concentrated  food.  Its  main  quality 
is  its  fitness,  in  concentration  and  ready  assimilation,  to  tide  the  organism 
over  an  emergency ;  but  it  is  not  usually  beneficial  when  employed  for  a  long 
period  as  a  constant  article  of  food,  for  it  tends  to  exhaust  the  irritability  of 
the  heart,  and  is  provocative  of  inflammation,  as  a  chemical  irritant,  in  the 
tissues  of  the  stomach  and  liver.  A  pure  spirit  given  in  small  quantity,  with 
milk,  is  the  best  and  most  available  form  of  stimulus  for  prompt  effect ;  it 
acts  most  certainly  and  directly  upon  the  heart.  Wine-whey  is  agreeable  and 
serviceable.  Of  wines,  champagne  is  grateful  in  an  emergency  ;  for  regular 
use  those  containing  tannin,  of  which  pure  Bordeaux  of  an  ordinary  quality 
is  the  type,  are  the  best  blood-makers. 

Nursing,  at  the  present  day,  has  taken  a  very  prominent  attitude  as  the 
executive  or  administrative  element  in  the  treatment  of  surgical  cases  of  dis- 
ease ;  it  has  been  reduced  to  an  art,  of  which  the  students  are  subjected  to 
regular  training,  with  the  result  of  producing  a  positive  diminution  of  mor- 
tality, in  the  aggregate,  of  surgical  cases  treated  by  their  aid,  as  shown  in 
hospital  practice. 

A  trained  woman  is  always  preferable  to  a  man  as  a  nurse,  wherever  her 
physical  capacity  is  equal  to  the  duty,  and  no  other  consideration  forbids. 
There  should  be  but  one  nurse  in  charge  of  a  patient  at  one  time,  and  this 
nurse  should  be  held  responsible  for  all  the  minuter  details  of  the  patient's 
management,  and  should  exercise  paramount  authority,  under  the  surgeon's  in- 
structions. Any  divided  allegiance  on  the  part  of  the  nurse  imperils  the 
safety  of  the  patient.  A  nurse  should  be  competent  to  take  the  patient's 
temperature  and  pulse,  and  record  them,  as  well  as  the  hours  at  which  food 
and  medicines  are  administered.  [Nature's  processes  are  conducted  in  accord- 
ance with  a  system  ;  and  if  we  assume  the  office  of  ministering  to  them  in 
the  way  of  aid,  or  of  attempting  to  modify  or  control  them,  our  efforts  must 
be  conducted  not  only  intelligently,  but  systematically. 

Medicines  Employed  in  the  Treatment  of  Inflammations. — In  discussing 
the  virtues  of  drugs,  we  are  entirely  in  the  domain  of  empiricism.  They  are 
to  be  judged  of  by  evidence  derived  from  observation,  and  this,  as  is  proved 
by  the  conflicting  opinions  held  by  men  otherwise  equally  reliable,  is  often 
faulty.  As  in  regard  to  the  value  of  blood-letting  as  a  remedy,  the  general 
and  apparently  established  sense  of  the  profession  may  undergo  a  radical 


156  INFLAMMATION. 

change.  Experiments  upon  animals  have  a  more  fixed  and  reliable  value, 
but  it  is  restricted  within  narrow  limits. 

Amongst  the  articles  of  the  Materia  medica  which  have  been  found  useful 
in  the  treatment  of  inflammation,  opium  has  the  first  place.  Its  great  virtues 
in  lessening  pain  and  securing  quietude  of  mind  and  body  have  been  already 
under  consideration.  Chloroform  and  sylph  uric  ether  are  invaluable  in  sur- 
gery, and  they  exercise  a  certain  controlling  influence  over  the  inflammatory 
condition,  mainly  as  preventives,  which  is  generally  recognized,  but  very  dif- 
ficult to  define.  It  is  apparently  due  to  their  wonderful  power  of  temporarily 
abolishing  physical  pain  and  mental  consciousness,  and,  possibty,  textural  sen- 
sibility to  harmful  influences,  and  of  preventing  vital  exhaustion — as  we  wit- 
ness it  in  the  shock  of  injury — by  economizing  the  nerve  force.  Secondarily, 
anaesthetics  tend  to  avert  inflammation  by  facilitating  the  manipulations  of 
the  surgeon  in  operations,  and  in  the  dressing  of  wounds.  Shortly  after  their 
first  introduction,  anaesthetics  were  unjustly  blamed  for  some  of  the  bad  re- 
sults of  surgical  injuries  and  operations ;  in  the  reaction  of  professional  opinion, 
after  nearly  half  a  century  of  experience  in  their  use,  they  are  credited,  more 
justly,  amongst  the  great  advantages  which  they  have  conferred  upon  man- 
kind, with  the  power  of  diminishing,  in  a  certain  degree,  the  sensibility  of 
the  organism  under  injury,  and  the  tendency  to  excessive  inflammatory  re- 
action. 

Quinine  is  a  most  valuable  medicine.  After  opium,  there  is  none  more  con- 
stantly employed  in  the  practice  of  surgery.  As  a  tonic  it  occupies  the  first 
rank,  promoting  the  failing  appetite,  aiding  the  digestion,  and  serving,  like 
food,  to  directly  increase  the  generation  of  nerve  force.  As  an  antidote  to  the 
poison  which  causes  ague,  and  the  fevers  we  call  malarial,  it  is  pre-eminent. 
If  this  poison  is  cryptogamic,  as  is  more  than  probable,  quinine  is  to  be  ranked 
high  amongst  the  antiseptics.  In  the  third  place,  quinine  has  the  singular 
power  of  reducing  the  temperature  of  the  blood  in  fever,  and  in  the  possession 
of  this  quality  it  is"  almost  alone.  It  is  not  surprising  that,  possessing  quali- 
ties which  meet  so  many  and  such  important  indications,  quinine  should  be 
so  constantly  prescribed  in  surgical  practice.  Naturally  there  is  a  disposition 
to  carry  the  use  of  so  valuable  a  remedy  to  excess,  both  in  administering  it  in 
a  vague  and  perfunctory  way  without  any  distinctly  recognized  indication  for 
its  use — simply  because  quinine  usually  does  good — and  also,  by  giving  it  in 
extravagant  and  excessive  doses.  Quinine  in  very  large  doses — twenty  grains, 
and  over — undoubtedly  produces  effects  which  cannot  be  otherwise  secured, 
but  it  is  required  in  this  way  only  in  exceptional  cases,  and  for  a  short  time ; 
and  these  effects  are  generally  due  to  its  quality — through  its  sustaining  influ- 
ence upon  the  nervous  centres — of  preventing  poisonous  influences  from  raising 
the  temperature  of  the  blood.  There  is  probably  no  poison  against  which 
quinine  acts  as  an  antidote  in  a  curative  way  except  the  poison  of  ague.  It 
was  quite  positively  asserted  not  long  since,  by  Helmholtz,  to  be  an  antidote 
to  the  poison  which  causes  "hay  fever;"  but  evidence  as  to  any  benefit  from 
it-  use  in  lliis  affection  is  wanting. 

What  shall  be  said  of  mercury,  the  drug  which  has  been  styled  the  Samson 
of  the  materia  medica?  Is  it  proper  to  speak  of  this  most  useful  rcmedjr  as 
an  antiphlogistic?  Docs  it  possess  any  curative  influence  over  the  inflamma- 
tory condition — excepting  always  its  qualities  as  an  efficient  and  manageable 
cathartic,  and  its  revulsive  action  upon  the  intestinal  canal — beyond  its  su- 
preme power  in  favorably  modifying  the  manifestations  of  syphilis?  The 
weighl  of  prevalent  opinion  tends  to  answer  these  questions  negatively.  The 
prestige  enjoyed  by  tins  drug  is  mainly  due  to  the  remedial  effects,  which  it 
produces  with  almost  invariable  certainty,  in  all  the  multiform  symptoms 
which  are  caused  by  the  presence  in  the  blood  of  the  syphilitic  virus.    As  most 


TREATMENT   OF   INFLAMMATION.  157 

of  these  symptoms  partake  of  the  inflammatory  character,  the  reputation  of 
mercury  as  an  antiphlogistic,  because  it  removes  them  so  readily,  is  explained. 
The  visible  melting  away  under  the  mercurial  influence  of  the  solid  exuda- 
tion often  present  in  iritis,  is  constantly  referred  to  as  demonstrating  the 
power  of  mercury  to  control  inflammation.  But  iritis  was  not  recognized  as 
a  consequence  of  syphilis  until  1801,  when  it  was  pointed  out  by  Beer;  and, 
at  present,  its  non-traumatic  occurrence  under  any  other  influence  than  that 
of  syphilis  is  regarded  as  exceedingly  rare.  We  have  no  evidence  that  mer- 
cury will  prevent,  or  cause  the  absorption  of,  the  inflammatory  exudation  in 
pleurisy  and  peritonitis.  In  the  latter,  although  no  combination  of  drugs 
ever  enjoyed  more  general  confidence,  opium,  alone,  has  noticeably  replaced 
the  calomel  and  opium  of  the  last  generation.  There  is  apparently  valid  evi- 
dence of  the  power  of  mercury  to  arrest  acute  bronchitis  and  acute  cystitis, 
the  symptoms  yielding,  as  is  asserted,  as  soon  as  the  specific  action  of  the 
mercury  becomes  manifest  in  the  mouth ;  but  in  the  cases  which  serve  as  a 
basis  for  this  opinion,  opium  has  also  been  administered  in  combination  with 
the  mercury. 

As  local  applications,  the  lotions  and  ointments  containing  mercury  are 
deservedly  held  in  estimation  as  possessing  salutary  qualities  beside  their 
stimulating  action.  These  qualities  are  habitually  described  by  the  rather 
vague  term  alterative.  "  Yellow  wash,"  "  black  wash,"'  mercurial  ointment, 
and  the  cerates  of  "  red''  and  "  white  precipitate"  are  universally  employed 
for  tocal  medication,  especially  in  unhealthy  and  chronic  surface  inflammations. 

The  preparations  of  lead  are  much  prized  in  surgery  for  their  sedative  and 
astringent  properties.  The  emplastrum  plumbi  as  an  unirritating  retentive 
agent  is  simply  invaluable.  "  Goulard's  lotion,"  a  dilute  solution  "of  the  sub- 
acetate,  is  justly  popular.  The  nitrate  is  more  astringent,  and  also  effective 
as  a  deodorizer ;  it  has  been  used  as  a  lotion  in  open  cancerous  ulcerations. 
The  acetate,  given  internally  in  combination  with  opium,  has  a  certain  value 
as  a  sedative  and  haemostatic.  The  soluble  preparations  of  lead  are  all 
deodorizers  in  consequence  of  the  readiness  with  which  they  decompose 
hydrosulphuric  acid  gas  ;  and,  for  the  same  reason,  dressings  containing  lead 
are  liable  to  blackish  discoloration  from  contact  of  this  gas,  which  is  always 
produced  by  decomposing  pus. 

The  astringency  and  unirritating  properties  of  the  oxide  and  sulphate  of 
zinc  give  them  also  great  value  as  local  applications  in  surface  inflammations 
in  the  form  of  cerates  and  lotions.  The  oxide,  mingled  with  pulverized 
starch,  is  used  to  dust  over  raw  surfaces  to  promote  their  scabbing ;  the 
benzoated  ointment  of  the  oxide  of  zinc  has  replaced  the  old  "  calamine" 
salve  in  popularity ;  and  solutions  of  the  sulphate  are  widely  used  as  lotions 
and  injections  in  inflammatory  conditions  of  mucous  membranes. 

The  depleting  and  depressing  effects  of  saline  laxatives  were  formerly  held 
in  much  esteem  in  inflammatory  affections  ;  but  the  fact  that  their  action  is 
secured  at  the  expense  of  direct  irritation  of  the  blood-making  intestinal 
surface,  constitutes  an  objection  to  their  use,  save  in  the  exceptional  cases 
which  by  the  suddenness  of  their  invasion,  or  the  violence  of  the  inflam- 
matory action,  in  a  robust  subject,  justify  this  somewhat  expensive  mode  of 
depletion  and  counter-irritation. 

Apart  from  its  depleting  and  disturbing  influence  upon  the  digestive  sur-i 
faces,  a  mild  but  effectual  cathartic  is  usually  required  in  the  beginning  of  a 
surgical  case,  and  not  unfrequently  during  its  progress,  to  remove  possible  fecal 
accumulations  in  the  large  bowel.  In  surgical  cases  requiring  rest  in  bed — 
as  where  bones  are  fractured — this  measure  is  to  be  kept  in  view  as  necessary 
to  favor  healthy  constructive  inflammation.  All  possible  disturbance  of  the 
patient  is  to  be  avoided  by  selecting  an  unirritating  aperient,  and  by  aiding  its 


158  INFLAMMATION. 

action  at  the  proper  time  by  an  enema  of  tepid  water  and  a  bed-pan  of  proper 
shape;  In  inflammation  of  joints,  and  in  fracture,  all  risk  of  possible  over- 
action  of  a  cathartic  is  to  be  carefully  guarded  against,  for  positive  harm  to 
the  inflamed  or  injured  parts  is  likely  to  be  caused  by  the  disturbance. 

There  is  no  drug  which  exerts  a  more  positive  and  undeniable  power  over 
a  local  development  of  inflammation  than  colchicum  in  a  crisis  of  genuine 
podagra  ;  but  its  good  effects  are  limited  to  this  disease.  A  knowledge  of 
the  modus  operandi  of  colchicum  in  producing  resolution  of  such  intense 
manifestations  of  inflammation  as  those  which  characterize  an  attack  of  acute 
gout,  would  be  of  great  interest  if  ascertainable.  It  seems  to  neutralize  the 
poison  in  the  blood,  or  to  eliminate  it  by  some  emunctory,  so  as  to  save  the 
white  fibrous  tissues  from  its  noxious  preference. 

Aconite  and  veratrum  viride  have  been  extolled  for  their  anti-inflammatory 
virtues,  and  many  excellent  practitioners  believe  in  their  salutary  influence. 
But  this  faith  is  waning.  Like  digitalis,  these  drugs  produce  certain  quasi- 
antiphlogistic  phenomena,  such  as  slowing  the  pulse  and  diminishing  heat- 
production,  but  this  effect  is  accomplished  by  their  specific  action  upon  the 
organism,  as  poisons ;  it  is  analogous  to  that  which  accompanies  the  shock 
of  injury,  and  tends  in  no  respect  to  remove  the  causes  of  the  fever  or  inflam- 
mation, although  certain  of  their  symptoms  may  be  temporarily  controlled. 
These  are  remedies  addressed  to  symptoms  only  ;  they  are  unphilosophical, 
and  their  value  is  more  than  doubtful.  Stille  sums  up  the  evidence  against 
veratrum  viride  in  terms  which  are  conclusive,  and  ends  with  the  solitary 
saving  clause,  that  it  may  possibly  do  good  in  "  cases  of  imminent  or  commenc- 
ing congestion  or  inflammation,  in  which  the  maintenance  of  its  sedative 
action  upon  the  heart  for  a  short  period  allows  the  conservative  powers  of 
the  system  to  operate  within  normal  limits." 

For  reasons  similar  to  those  which  are  now  accumulating  force  against 
these  depressing  remedies,  tartar  emetic  also  has  fallen  into  disuse.  This 
drug  was  formerly  held  in  estimation  as  second  only  to  general  bleeding  in  its 
power  of  controlling  excessive  vascular  action ;  but  through  the  same  con- 
siderations which  have  brought  blood-letting  into  disrepute,  all  these  depres- 
sants are  at  present  regarded'by  the  profession  with  diminishing  confidence. 

As  the  science  of  surgery  has  advanced,  the  indications  for  the  treatment 
of  surgical  diseases  have  "become  more  precise;  and  it  is  desirable  that  these 
indications  should  always  be  sought  for,  and  carefully  studied.  Otherwise 
the  practitioner  is  in  danger  of  becoming  a  routinist,_  instead  of  a  scientific 
surgeon.  Many  remedies  "formerly  in  repute  and  sanctioned  by  the  authority 
of  great  names,"  have  lost  their  prestige,  and  are  no  longer  in  use ;  or  are  em- 
ployed only  in  deference  to  custom  and  authority,  and  in  a  perfunctory 
way.  Some  of  these  remedies  enjoyed  great  popular  favor,  a  share  of  which 
extended  to  the  surgeon  who  employed  them;  and  this  circumstance  has 
tended  to  perpetuate  their  use.  Even  now  a  .patient  from  the  old  countries 
will  often  crave  a  bleeding  from  the  arm  as  a  right,  through  traditional  con- 
fidence in  its  virtue. 

In  the  growth  of  more  precise  knowledge  in  pathology,  the  doctrine  of 
blood-poisons,  now  dominant,  is  undoubtedly  a  principal  cause  of  the  changes 
which  have  taken  place  in  the  treatment  of  inflammation,  especially  as  to  the 
reluctance  to  employ  depressing  remedies.  The  general  use  of  the  micro- 
scope has  revealed  the  infinitely  delicate  and  elaborate  structure  of  our  tis- 
sues and  organs,  and  has  begotten  a  salutary  indisposition  to  interfere  with 
the  vitality  of  their  anatomical  elements  by  means  of  agents  which  are  harsh 
and  violent  in  their  action. 


TREATMENT    OF   INFLAMMATION.  150 

Antiseptics,  as  has  been  already  remarked,  are   replacing  antiphlogistics  ; 

and  we  find  ourselves,  therefore,  obliged  to  consider  the  claims  of  the  former 
as  remedies  for  inflammation.  Amongst  the  antiseptic  substances  which  have 
recently  attained  prominence,  carbolic  acid  holds,  at  present,  the  first  place. 
This  drug,  practically  introduced  to  the  profession  by  Lister,  owes  its  pre- 
eminence as  an  antiseptic  to  its  volatile  and  pervading  quality,  in  addition 
to  its  power  of  destroying  the  vitality  of  the  lower  forms  of  life  without 
seriously  endangering  that  of  the  human  organism.  There  is  no  other  of  the 
antiseptic  substances  daily  brought  within  our  cognizance  which  possesses 
this  combination  of  equalities  in  so  eminent  a  degree.  But  chemistry  may  at 
any  time  present  us  with  a  substitute  possessing  superior  qualities.  Beyond 
this  power  of  destroying  the  vitality  of  microscopic  organisms  which  are 
noxious  to  our  vital  processes,  and  thus  protecting  us  from  their  harmful 
action,  there  is  no  positive  evidence  that  carbolic  acid  possesses  any  positively 
controlling  quality  as  regards  excessive  vascular  action,  or  any  other  of  the 
manifestations  of  destructive  inflammation.  It  simply  secures  for  us  free  play 
for  our  reparative  processes.  This  is  the  sum  and  substance  of  the  antiseptic 
method  of  dressing  wounds.  Some  of  the  other  prominent  antiseptics  which 
have  recently  come  into  use,  possess  additional  qualities.  Thus  salicylic  acid, 
which  is  restricted  in  its  antiseptic  applications  in  consequences  of  its  lack  of 
volatilit}T,  has  the  power  of  lowering  the  temperature  of  the  blood,  and  of 
controlling  rheumatic  inflammation. 

The  additions  to  our  materia  medica  to  be  anticipated  in  the  discovery  of 
new  antiseptics,  especially  of  those  with  peculiar  powers,  promise,  Avith  what 
has  been  already  gained  for  humanity  in  this  direction,  to  add  to  our  reme- 
dies in  inflammation  far  more  than  we  have  lost  by  the  exclusion  of  anti- 
phlogistics. It  will  be  a  great  gain  to  the  science  of  surgery  that  the  mode 
of  action  of  these  remedies  can  be  explained  on  a  basis  of  rational  therapeu- 
tics. 


ERYSIPELAS. 


BY 


ALFRED  STILLE,  M.D.,  LL.D., 

PROFESSOR  OF  THE  THEORY  AND  PRACTICE  OF  MEDICINE  AND  OF  CLINICAL  MEDICINE  IN  THE  UNIVERSITY 

OF  PENNSYLVANIA,  PHILADELPHIA. 


Synonyms. 

English,  Erysipelas,  the  rose,  St.  Anthony's  Jire  ;  French,  Erysipele,  la  rose,  feu 
sacre,feu  St.  Antoine ;  German,  Rose,   Wundrose,  Rothlauf ;  Italian,  Risipola. 

Erysipelas  was  originally  a  Greek  word,  but  there  is  no  general  agreement 
respecting  its  etymology.  That  most  generally  adopted  is  that  it  is  derived 
from  "tpvtiv  (to  draw)  and  7ti%as  (near),  "to  draw  near,"  because  the  name  is 
supposed  to  indicate  the  spreading  or  wandering  character  of  the  eruption. 
Others  derive  it  from  i pi>0p6s  (red)  and  7tt-k6$  (livid),  "  livid  redness,"  or  from 
ipv9p6{  and  *sM.a,  "red  skin."  But  an  objection  to  the  last  etymology  is  that 
the  Greek  word  Ttiixa  does  not  mean  skin. 

Erysipelas  may  be  defined  as  an  acute,  specific,  and  contagious  fever,  tend- 
ing usually  towards  a  typhoid  type,  and  characterized  locally  by  a  peculiar 
inflammation  of  the  skin  or  mucous  membranes.  It  may  attack  the  same 
person  more  than  once. 


History  of  Erysipelas. 

Erysipelas  has  been  known  from  the  earliest  periods  of  medical  history. 
Hippocrates  gives  a  very  particular  account  of  it.1  He  relates  that  during 
a  certain  cold  spring,  many  cases  of  erysipelas  occurred  with  sore  throat  and 
loss  of  speech,  adding  that  they  were  malignant  and  fatal.  In  many  also,  as 
from  an  accident,  and  sometimes  even  from  a  small  wound,  and  especially  in 
old  persons,  or  if  the  wound  were  neglected,  a  great  inflammation  took  place, 
and  the  erysipelas  spread  all  over.  In  most  instances,  the  inflammation 
ended  in  abscesses,  and  the  flesh,  tendons,  and  bones  sloughed.  It  is  particu- 
larly noticed  that  the  discharge  was  not  like  pus,  but  a  sort  of  putrefaction, 
or,  as  it  would  now  be  described,  a  sanious  and  ichorous  discharge.  When 
the  scalp  was  attacked,  Ave  are  told,  the  hair  was  apt  to  fall,  and  even  the 
bones  of  the  skull  to  exfoliate ;  and,  it  is  added,  bad  as  these  symptoms  were, 
they  involved  less  danger  than  when  the  disease  was  determined  inwardly. 
In  some  cases,  it  is  said,  the  whole  arm  might  drop  off,  and  the  bones  of 
the  thigh,  leg,  and  foot  be  laid  bare;  but  the  most  formidable  cases  were  those 
which  involved  the  pubes  and  the  genital  organs.  This  author  briefly  states 
the  case  of  a  man  who  had  erysipelas  of  tlie  foot  and  leg,  with  phlyctense, 

1  Epidemics,  Book  III. 
VOL.  L— 11  (  161  ) 


162  ERYSIPELAS. 

and  who  became  delirious  and  died  on  the  second  day ;  and  he  points  out  the 
exceptional  gravity  of  the  disease  when  it  invades  the  head.  Under  the 
name  of  cancer,  Celsus1  describes  a  rodent  ulcer  around  which  the  skin  may 
grow  red  and  painful,  which  condition,  he  adds,  the  Greeks  called  tpvainiias, 
adding  that  not  only  does  it  attack  wounds,  but  it  may  also  arise  idiopathi- 
cally,  and  that  it  becomes  very  dangerous  when  it  affects  the  neck  and  head. 
From  the  time  of  Galen,  accuracy  of  description  was  sacrificed  to  elaborate 
speculations  concerning  the  nature  of  the  disease,  which,  it  was  agreed,  arose 
'  from  a  bilious  humor  that  tended  to  escape  from  the  skin  where  it  occasioned 
the  local  phenomena  of  erysipelas. 

Behind  the  veil  of  this  myth  is  discernible  the  idea  that  the  disease  is  not  to 
be  regarded  as  a  local  affection  merely.  In  accordance  with  such  belief,  which 
was  doubtless  sustained  by,  if  it  did  not  originate  in,  the  frequent  occurrence 
of  bilious  vomiting  at  the  commencement  of  an  attack  of  erysipelas,  emetics 
and  cholagogue  purgatives  were  enjoined  as  appropriate  remedies,  and  they 
continue  to  be  used,  but  upon  more  rational  grounds,  at  the  present  day.  On 
the  other  hand,  a  recognition  of  the  frequent  topical  course  as  well  as  origin 
of  erysipelas,  is  just  as  clearly  indicated  by  the  mode  of  treating  it  which  pre- 
vailed among  the  later  Greeks  and  the  Romans,  by  means  of  astringent  and 
refrigerant  applications.  Caution,  however,  was  strongly  enjoined  b}r  them 
lest  a  too  active  or  too  prolonged  treatment  of  this  description  should  induce 
gangrene ;  and  Galen,  as  well  as  his  successors,  directed  that  when  cooling 
(narcotic)  herbs,  vinegar,  potter's  clay,  preparations  of  lead,  verdigris,  sulphur, 
alum,  and  other  sedative  astringents  failed,  and  the  parts  grew  livid,  the 
skin  should  be  incised  and  warm  fomentations  and  poultices  applied  to  it. 
The  resulting  ulcer,  if  one  occurred,  was  to  be  dressed  with  honey  or  rose-oil 
rendered  stimulant  or  astringent  by  the  addition  of  wax,  rosin,  myrrh,  etc. 
Nightshade,  henbane,  lettuce,  horned  poppy,  opium,  cicuta,  and  mandragora 
are  also  mentioned  as  proper  dressings  during  the  inflammatory  stage  of  the 
disease.  A  poultice  of  bread-crumb  with  rose-oil,  saffron,  and  opium,  was 
applied  in  anal  erysipelas.  The  Arabians  omitted  from  their  method  of  treat- 
ing erysipelas  the  more  repressive  topical  agents  of  the  Galenical  school,  but 
retained  the  cataplasms  and  other  lenitive  applications;  they  administered 
gentle  cholagogues  and  laxatives,  and,  while  favoring  venesection  in  sthenic 
cases,  and  especially  in  erysipelas  of  the  head,  warned  against  the  tendency  to 
exhaustion  characteristic  of  the  disease.  In  this,  however,  they  only  followed 
Paulus  .zEgineta,  who,  after  describing  "  erysipelas  of  the  brain,"  advised  de- 
pletion from  the  ranine  veins,  and  cooling  applications  to  the  scalp. 


Causes  of  Erysipelas. 

General  Causes. — Whatever  may  be  the  specific  cause  of  erysipelas,  there 
is  little  doubt  that  certain  external  conditions  favor  its  production,  or  at  least 
its  propagation.  But  care  should  betaken  to  distinguish  between  those  which 
are  essential,  and  those  which  are  casual  and  contingent.  It  would  be  a  waste 
of  time  to  inquire  into  the  greater  or  less  susceptibility  to  the  disease  of  per- 
sons of  opposite  sexes  or  different  ages.  Apart  from  the  inherent  vigor  of 
certain  persons  as  compared  with  others,  there  is  no  real  difference  to  be  noted, 
[ndeed,  as  far  as  individuals  are  concerned,  the  chief  distinction  relating  to 
their  liability  to  erysipelas  depends  upon  whether  they  present  or  not  some 
lesion  of  the  skin,  and  whether  or  not  they  have  breamed  an  atmosphere 
charged  with  effluvia  from  a  source  capable  of  generating  the  disease.     The 

1  Lib.  v.  cap.  xxvi.  sect.  31. 


CAUSES    OF   ERYSIPELAS.  163 

character  of  those  sources  will  be  pointed  out  presently.  Meanwhile  it  may 
be  stated  that  the  exposure  to  such  effluvia  of  any  wound,  great  or  small,  in- 
cised, lacerated  or  punctured,  recent  or  chronic,  healthy  or  unhealthy,  suppu- 
rating or  not,  may  be  sufficient  to  admit  the  virus  of  the  disease.  And  equally 
is  it  true  that  any  mucous  membrane  similarly  exposed  to  receive  that  virus, 
may  become  the  channel  of  its  introduction  into  the  system.  These  facts  must 
always  be  taken  into  account  while  studying  the  general  influences  which 
seem  to  determine  more  or  less  the  prevalence  of  the  disease.  Thus  it  is  often 
said  that  the  total  number  of  cases  of  erysipelas,  and  their  proportionate  mor- 
tality, are  greater  during  the  winter  and  spring  months,  or  from  October  to 
March  inclusively,  than  during  the  summer  and  autumn,  or  from  April  to 
September  inclusively.  But  to  infer  from  this  statement  that  cold  weather 
was  a  cause,  predisposing  or  exciting,  of  the  disease,  would  be  unwarrantable; 
since  it  is  perfectly  intelligible  that,  if  the  disease  were  propagated  by  a  mate- 
rial poison,  it  would  be  more  prevalent  and  fatal  in  close  rooms  during  the 
winter,  than  in  well-ventilated  summer  wards  or  apartments.  In  point  of  fact, 
however,  the  rule  is  not  absolute,  and  it  has  happened  that  epidemics  which 
began  in  the  winter,  have  reached  their  height  only  during  the  following 
summer.  One  of  the  worst  epidemics  of  erysipelas  on  record  prevailed  at 
Paris  in  the  summer  of  1861. 

It  is  often  remarked  that  erysipelas  is  apt  to  prevail  or  increase  during 
cold  and  damp  weather,  and  when  the  wind  is  easterly,  and  it  has  been  charged 
that  the  habit  of  ventilating  certain  hospital  wards  in  London,  and  elsewhere 
in  the  north  of  Europe,  by  opening  the  windows  widely  while  the  wind  blew 
from  the  east,  was  frequently  the  means  of  producing  and  extending  the  dis- 
ease. That  being  chilled  sometimes  develops  erysipelas,  seems  certain;  and 
some  persons  have  attributed  to  cold  a  direct  and  independent  power  of  pro- 
ducing it,  on  the  strength  of  such  cases  as  the  following: — 

A  man  subject  to  articular  rheumatism  was  exposed  to  cold  and  wet,  and  after  a  chill 
was  attacked  with  fever,  and  articular  pains  in  a  limb  which  presently  became  swollen, 
red,  and  covered  with  phlyctena? ;  after  a  time  the  skin  broke  and  discharged  a  large 
amount  of  sanious  liquid,  and  then,  as  the  patient  was  growing  convalescent,  he  was 
attacked  with  erysipelas  of  the  face,  which  ran  its  usual  course.1 

In  this  case,  it  is  not  certain  that  cold  was  the  only  morbid  cause  to  which 
the  patient  was  exposed.  Of  the  case  reported  by  Mr.  Beale,2  in  which  a  child 
three  weeks  old  was,  without  known  cause,  attacked  with  phlegmonous  ery- 
sipelas of  the  left  leg  and  thigh,  which  speedily  proved  fatal,  it  can  only  be 
said  that  the  cause  was  unknown.  Certainly,  in  many  cases,  erysipelas  of  the 
face  follows  exposure  to  cold,  and  especially  to  cold  winds  ;  but  how  far  cold 
may  be  regarded  as  an  essential  cause,  is  uncertain.  In  like  manner  cached!*: 
conditions  seem  to  favor  the  development  of  the  disease,  but  probably  only  by 
lessening  resistance  to  the  morbid  poison  on  which  the  disease  more  directly 
depends.  It  would  seem  that  Bright's  disease  in  a  special  manner  consti- 
tutes such  a  predisposition,  as  appears  in  the  -following  instance  related  by 
Mr.  Fergusson: — 3 

A  woman  of  intemperate  habits,  who  had  albuminous  urine,  pricked  her  thumb  ;  the 
wound  soon  grew  painful  and  erysipelatous,  and  the  inflammation  in  a  phlegmonous 
form  spread  rapidly  to  the  whole  limb,  terminating  fatally  about  the  ninth  day. 

The  difficulty  of  accounting  for  attacks  of  erysipelas  is  aptly  illustrated  by 
the  remark  of  Mr.  Callender^  made  as  lately  as  1878,4  that  they  sometimes 

1  Denoyer,  Archives  Generates  de  Medecine,  Dec.  1878,  p.  719. 

2  Lancet,  March,  1800,  p.  293.  3  Medical  Times  and  Gazette,  Aug.  1868,  p.  211. 
St.  Bartholomew's  Hospital  Reports,  vol.  xiv.  p.  185. 


164  ERYSIPELAS. 

seem  "  to  grow  out  of  the  irritation  caused  by  some  acrid  secretion  by  error 
allowed  to  remain  in  a  wound."  The  term  "  acrid  secretion"  is  familiar  but 
indefinite,  and  is  hardly  to  be  accepted  as  correct  in  regard  to  any  liquid  at 
the  moment  of  its  secretion.  But  although  any  such  liquid  may  become  acrid  by 
putrefaction,  it  is  well  known  that  no  such  change  is  necessary  to  produce  even 
traumatic  erysipelas,  and  to  that  alone  the  above  remark  applies.  Neverthe- 
less, the  proofs  of  the  origin  of  many  cases  of  erysipelas  in  the  emanations  of 
decomposing  organic  matter  are  conclusive.  Of  this  statement  some  illustra- 
tions may  here  be  given.  Dr.  Begbie  published  several  cases  of  erysipelas, 
one  of  which  was  traceable  to  the  emanations  of  decomposing  vegetable  mat- 
ter.1 It  is  of  interest  in  this  instance  to  remark  that  the  family  attacked 
was  from  the  country,  and  newly  arrived  in  Edinburgh,  while  the  other  in- 
mates of  the  infected  house  had  long  been  resident  there,  and  had  doubtless 
become  seasoned  to  its  poisonous  atmosphere. 

Several  years  ago  an  English  writer  used  this  language:  "There  is  now  no 
more  doubt  that  erysipelas  is  originated  by  sewer  gas  than  that  typhoid  fever 
is  more  often  than  not  due  to  impure  water."2  In  numerous  instances  the 
prevalence  of  the  disease  has  been  proved  to  be  coincident  with  the  presence 
of  choked  drains,  drains  communicating  with  town  sewers,  or  drains  which 
had  become  permeable  to  fecal  gases  or  liquids  either  by  the  corrosive  action 
of  their  contents  or  by  the  gnawing  of  rats,  while  the  subsidence  of  such  local 
epidemics  has  coincided  with  a  reformation  of  the  existing  defects  in  venti- 
lation, sewerage,  and  water  supply.  As  an  example  of  these  agencies,  the 
case  of  the  Somerset  County  (England)  Lunatic  Asylum  may  be  cited.  Be- 
tween December  and  the  following  May ,  thirty-two  cases  of  erysipelas  occurred, 
of  which  four  proved  fatal,  and,  on  investigation,  it  was  found  that  none  of 
the  soil  pipes  were  ventilated ;  one  of  them  had  a  communication  with  the 
main  sewer;  most  of  them  were  of  lead,  and  several  of  these  were  eaten  and 
riddled  with  holes ;  and  the  main  drain  had,  on  one  occasion,  been  blocked 
entirely  to  the  extent  of  three  or  four  yards.  According  to  the  same  authority, 
in  a  large  London  hospital,  pyaemia  and  erysipelas  had  prevailed  to  a  deplo- 
rable extent,  and,  on  examination,  its  means  of  ventilation  were  found  to  be 
very  defective ;  but  as  soon  as  the  defects  were  corrected  and  the  pressure 
removed  from  the  traps  of  the  closets  and  lavatories,  no  fresh  cases  occurred. 
In  another  instance,  an  epidemic  of  the  disease  was  distinctly  traced  to  the 
stopping  up  of  a  ventilation-pipe  by  a  careless  workman. 

The  Sanitary  Reports  of  England  contain  numerous  instances  which  prove, 
like  those  just  cited,  that  outbreaks  of  erysipelas,  as  well  as  of  hospital  gan- 
grene and  of  fevers,  are,  with  scarcely  an  exception,  connected  with  serious 
defects  of  drainage  or  ventilation,  or  with  a  lack  of  any  provision  for  isolat- 
ing infection,  or  with  some  of  these  defects  combined.  Thus,  at  the  Radcliffe 
Infirmary,  where  twenty-six  persons  affected  with  various  diseases  or  injuries 
had  been  attacked  with  erysipelas,  and  five  of  them  had  died  of  the  super- 
induced affection,  the  origin  of  the  outbreak  was  undoubtedly  owing  to  the 
imperfect  arrangement  of  the  drains,  added  to  crowding,  uncleanliness,  and 
bnperfecl  ventilation.  At  the  Royal  Infirmary,  Manchester,  recurring  out- 
breaks of  traumatic  erysipelas  had  taken  place,  which  were  traced  to  the  ex- 
cessively foul  drainage  and  to  the  overcrowding  of  the  house  with  patients 
and  attendants.  The  water-closets,  baths,  ward  offices,  and  drains  of  the 
infirmary  were  placed  within  the  building,  and  several  of  the  closets  were 
without  direct  communication  with  the  outer  air,  so  that  sewer  gas  escaping 
from  them  necessarily  passed  into  the  corridors  and  wards.     Under  such  con- 

'  Monthly  Journal  of  Medical  Science,  Sept.  18.r)2,  p.  243. 
2  London  Sanitary  Record,  June,  1879,  pp.  357,  37'J. 


CONTAGION   OF   ERYSIPELAS.  165 

ditions,  wounds  do  not  heal  but  are  apt  to  bo  attacked  with  erysipelas  or 
phagedsena ;  the  natural  processes  of  cicatrization,  by  which  a  firm  barrier  is 
established  between  the  lesion  and  the  system,  are  interfered  with ;  the  germs 
of  disease  and  the  products  of  putrefactive  change  are  absorbed  ;  and  erysipe- 
las and  septicaemia  ensue. 

Besides  the  sources  of  infection  now  described,  others  may  be  mentioned,  of 
which  the  following  are  examples.  In  Middlesex  Hospital,  London,  it  was 
observed  that  the  only  patients  attacked  with  erysipelas  in  a  certain  ward 
were  those  who  occupied  two  adjacent  beds.  After  long  searching  in  vain 
for  the  cause  of  this  peculiarity,  it  was  discovered  that  the  pipe  of  a  water- 
closet  which  ran  behind  the  plaster  of  the  wall  at  this  place,  was  defective. 
It  was  repaired  and  no  more  cases  of  erysipelas  occurred  at  the  time.  But 
ten  }Tears  later,  the  same  beds  became  again  unhealthy  with  erysipelas,  and 
the  same  remedy  put  an  end  to  the  disease.  A  perfectly  similar  case  occurred 
in  a  Berlin  hospital.1  Again,  in  the  hospital  at  Rostock,  it  was  found  that 
those  patients  only  who  had  recently  undergone  surgical  operations  were 
attacked  with  erysipelas.  After  various  fruitless  researches  the  pillows  of 
the  operating  tables  which  by  long  use  had  become  saturated  with  blood,  fell 
under  suspicion,  and  were  replaced  by  new  ones,  after  which  no  more  cases  of 
the  disease  occurred.  The  soiled  pillows  were  then  treated  with  hot  water, 
and  an  extract  procured,  with  which  two  rabbits  were  inoculated.  One 
escaped  unharmed ;  but  the  other  was  attacked  with  severe  inflammation  of 
the  skin  and  connective  tissue,  which  spread  extensively  and  was  accom- 
panied with  blisters,  gangrene,  and  fever,  from  which,  however,  the  animal 
finally  recovered. 

Contagion. — The  origin  of  erysipelas  which  has  been  described,  and  its  re- 
lations to  puerperal  fever  to  be  noticed  further  on,  would  of  themselves  render 
the  contagiousness  of  the  disease  probable.  But  direct  clinical  proof  is  also 
abundant  that  erysipelas  itself  is  communicable  by  contagion.  The  case  is 
well  known,  which  is  reported  by  Campbell,2  of  a  hospital  ward  in  which 
the  disease  travelled  from  bed  to  bed  in  regular  succession ;  but  the  following 
illustrations  of  the  same  import  should  be  impressed  upon  the  mind  of  every 
physician  and  surgeon. 

During  an  epidemic  of  "  putrid  sore-throat,"  which  prevailed  in  Dublin  after  an 
absence  of  more  than  twenty  years,  a  lady  was  attacked  with  sore-throat  and  fever,  and 
in  the  course  of  a  few  days  erysipelas  appeared  upon  her  face.  Her  son,  a  robust 
youth  of  eighteen,  who  helped  to  nurse  her,  got  "a  whiff  of  sickening  air  from  her  bed- 
clothes," and  immediately  suffered  from  headache  and  fever.  On  the  fourth  day 
he  complained  of  pain  in  the  shoulder,  followed  by  swelling  under  the  pectoral  muscles, 
which  increased,  and  on  the  tenth  day  this  region  was  covered  with  erysipelas  which 
spread  over  the  trunk.  Bulla?  formed,  succeeded  by  gangrene  ;  similar  lesions  affected 
the  scrotum;  and  death  took  place  on  the  fifteenth  day.3 

In  1852,  a  man  arrived  in  Platte  County,  Missouri,  suffering  from  erysipelas  of  the 
face.  He  was  nursed  by  a  farmer  who  himself  fell  ill  just  as  his  patient  was  beginning 
to  improve.  A  second  farmer  who  assisted  in  nursing  both  of  the  other  persons,  and 
slept  in  the  same  bed  with  them,  was  seized  with  the  disease,  and  subsequently  six 
other  persons  who  helped  to  nurse  the  former  patients  were  themselves  attacked.  Be- 
sides these,  no  other  cases  occurred  in  the  neighborhood.* 

Trousseau  relates  several  instances  of  the  contagiousness  of  the  disease.  In  a  cer- 
tain house,  the  person  first  attacked  died,  as  did  the  nurse  who  waited  on  him,  while 

1  Berliner  klin.  Wochenschrift,  1868. 

2  Zuelzer,  Ziemssen's  Handbucli,  Bd.  ii.  S.  416. 

3  Graves,  Clinical  Medicine,  p.  576. 

4  New  York  Journal  of  Medicine,  vol.  x.  p.  41. 


166  ERYSIPELAS. 

several  members  of  the  family  who  came  into  contact  with  those  first  affected  experi- 
enced serious  illness.  A  lady  contracted  the  disease  from  her  son,  a  young  physician 
who  had  caught  it  from  erysipelatous  patients  in  a  hospital.  A  gentleman,  whose  frae- 
num  prasputii  had  been  divided,  died  from  gangrenous  erysipelas  ;  shortly  afterwards 
his  wife,  who  had  attended  him  assiduously,  fell  a  victim  to  erysipelas  of  the  throat  and 
face,  and  the  lady's  maid  suffered  a  similar  attack,  from  which,  however,  she  recovered. 
A  gentleman  received  a  gunshot  wound  of  the  foot  followed  by  gangrenous  and  fatal 
erysipelas  ;  his  brother,  who  nursed  him,  was  attacked  with  erysipelas  of  the  scalp 
which  ended  in 'his  death  on  the  eighth  day;  his  daughter,  a  child  of  three  years,  had 
a  slight  burn  of  the  hand  which  became  erysipelatous ;  the  family  laundress  was 
affected  with  phlegmonous  erysipelas  of  the  right  hand  ;  the  sick-nurse  had  erysipelas 
of  the  face  and  head  ;  and  a  sister  of  charity,  charged  with  the  duty  of  irrigating  the 
wounded  foot,  had  a  phlegmonous  abscess  of  the  right  arm  followed  by  several  in  other 
parts  of  the  body,  which  sloughed,  and  finally  caused  the  woman's  death.  Meanwhile, 
however,  she  had  returned  to  her  convent,  where  a  number  of  the  sisters  were  similarly 
affected,  and  two  of  them  died.  A  hospital  physician  of  Bordeaux  admitted  a  patient 
with  ophthalmia,  placing  him  near  one  affected  with  phlyctenoid  erysipelas;  the  former 
took  the  disease,  and  the  physician,  who  had  a  slight  excoriation  of  the  lip,  was  also 
attacked.  He  was  attended  by  his  father,  who  was  likewise  a  physician,  and  who  con- 
tracted the  disease  and  communicated  it  to  his  sister-in-law  who  came  to  visit  him. 

Dr.  Mackay,  a  British  naval  surgeon,  testifies  strongly  to  the  contagious  nature  of 
erysipelas  as  it  was  exemplified  on  board  a  man-of-war.  The  ship  itself  after  thorough 
inspection  was  pronounced  exceptionally  pure,  and  the  only  source  of  the  disease  as  an 
epidemic,  seemed  to  be  a  case  of  "  erythema,"  in  a  cachectic,  syphilitic  sailor ;  for, 
from  his  attack,  and  from  contact  with  him,  the  subsequent  cases  appeared  to  take  their 
rise.     In  several  instances,  the  characteristic  throat  affection  existed. 

The  case  has  elsewhere  been  quoted,  but  is  appropriate  here,  of  a  physician  who, 
having  bled  a  person  suffering  under  erysipelas  following  a  burn,  bled  a  man  with  the 
same  lancet,  the  operation  being  followed  by  erysipelas  and  phlebitis,  and  also  a  woman 
who  was  attacked  with  puerperal  fever.1 

These  cases  all  belong  to  a  period  of  about  a  quarter  of  a  century  ago,  and 
at  that  time  the  reality  of  the  contagiousness  of  erysipelas  was  recognized  by 
clinical  observers;  long,  indeed,  before  it  was  admitted  by  scientific  men, whose 
vision  is  sometimes  more  acute  for  abstract  propositions  than  for  the  plain 
facts  of  experience.  Thus  the  great  surgeon,  Velpeau,  taught  that  erysipelas 
was  not  a  simple  inflammation  of  the  skin,  but  the  product  of  a  special  poison 
absorbed  from  without ;  and  several  other  leading  physicians  and  surgeons 
in  France  held  the  same  opinion. 

In  a  memoir  addressed  to  the  Academy  of  Medicine  of  Paris,  in  1865,  Blin  cites  the 
case  of  a  young  man  who,  after  nursing  in  Paris  a  friend  ill  with  erysipelas,  returned 
to  his  village,  where  for  a  long  time  no  case  of  the  disease  had  occurred.  Within  a 
fortnight  he  died  of  it;  then  a  servant  who  had  nursed  him  was  attacked,  but  recovered; 
a  friend  from  a  neighboring  commune,  which  was  free  from  the  disease,  came  to  visit 
the  patient,  after  which  he  was  attacked,  and  his  wife  also  a  little  later.  Four  other 
persons  who  visited  the  last  mentioned,  took  the  disease,  and  the  physician  who  attended 
them,  his  daughter,  and  the  religious  sister  who  nursed  them,  were  all  attacked,  the 
physician  fatally.  In  the  report  on  Blin's  memoir,  Gosselin  adverted  to  a  number  of 
analogous  examples,  and  others  were  referred  to  in  the  discussion  to  which  it  gave  rise. 
Nevertheless,  the  contagiousness  of  erysipelas  was  not  frankly  admitted,2  and  the  reporter, 
Gosselin,  in  a  later  article  on  the  disease,  appears  to  be  not  thoroughly  convinced  of  its 
contagiousnes  -.; 

In  confirmation  of  the  results  of  clinical  observation  which  have  now  been 
brought  forward  to  prove  the  contagiousness  of  erysipelas,  it  may  be  added 

1  American  Medical  Times,  April,  1863,  p.  198. 

2  Bulletin  de  L'AcadSmie,  t.  xxx.  p.  DO!). 

3  Nouveau  Dictionnaire  de  Mudeciue,  etc.  t.  xiv.  p.  40. 


SPECIFIC    CAUSE    OF   ERYSIPELAS.  167 

that  Mr.  Goodhart  has  collected  a  number  of  cases  from  hospital  practice,1 
which  show  that  erysipelas  may  be  communicated  to  persons  suffering  from 
diseases  of  the  urinary  passages,  by  means  of  an  infected  catheter,  and  that  the 
affection  thus  induced  may  be  attended  with  its  usual  constitutional  symptoms, 
with  an  erysipelatous  eruption  on  various  parts  of  the  skin,  and  with  serious 
and  often  fatal  inflammation  of  the  bladder  and  kidneys. 

Specific  Cause  of  Erysipelas. — Of  late  there  has  been  an  evident  leaning 
towards  the  adoption  of  the  theory  that  erysipelas  is  produced  by  a  specific 
virus.  At  all  times,  under  one  or  another  form,  this  doctrine  has  existed,  and 
indeed  it  afforded  the  only  rational  explanation  of  the  familiar  fact  that  in- 
fectious and  contagious  diseases  reproduce  themselves  under  uniform  types. 
Leuwenhoeck  discovered  bacteria  nearly  two  hundred  years  ago,  but  it  has 
required  this  long  period  to  develop  the  existing  doctrine  which  asserts  that 
every  one  of  such  diseases  depends  direct]}'  upon  a  specific,  organic  form.  The 
growth  of  this  theory  has  been  retarded  by  that  of  Zymosis,  which,  although 
purely  fanciful  in  its  conception,  acquired  such  authority  as  to  have  its  name 
applied  in  an  official  nomenclature  to  the  group  of  idiopathic  febrile  diseases.. 
But  even  if  it  were  true,  which  it  is  not,  that  one  and  the  same  bacterium  is 
uniformly  found  in  connection  with  the  same  disease,  the  manner  in  which  it 
occasions  the  specific  phenomena  of  that  disease,  would  thereby  become  no 
clearer.  It  has  been  suggested  that  each  specific  form  of  bacterium  secretes  a 
specific  virus,  which,  in  its  turn,  produces  the  specific,  morbid  type.  But  this 
is  evidently  an  attempt  to  explain  ignotum  per  ignotius.  The  present  state  of 
knowledge  and  opinion  upon  the  subject,  as  far  as  relates  to  the  disease  we 
are  engaged  in  studying,  is  perhaps  expressed  by  Orth,  whose  elaborate  ex- 
periments led  him  to  the  following  conclusions:2 — 

1.  Epidemic  traumatie  erysipelas  is  caused  by  a  poison  in  the  blood  as  well  as  in  the 

secretions  of  the  affected  part. 

2.  These  secretions  are  capable  of  producing  erysipelas  by  inoculation. 

3.  Bacteria  are  generated  pari  passu  with  the  development  of  erysipelas. 

4.  Bacteria  stand  intimately  related  to  the  septic  cause  of  erysipelas,  for  its  characteris- 

tic symptoms  may  be  produced  by  artificially  propagated  bacteria. 

5.  But  bacteria  are  only  an   indirect  cause  of  the  disease,  since   they  are  not  formed 

abundantly  in  the  blood  of  infected  animals,  and  because  they  may  be  removed, 
without  entirely  destroying  the  activity  of  the  infecting  liquid. 

6.  Bacteria  appear  to  belong  to  the  microspheres  and  the  schizomycetes. 

7.  It  is  probable  that  in  different  forms  of  the  disease  different  micro-organisms  occur,. 

but  thus  far  no  proof  of  this  proposition  exists. 

In  1879,  Tillmanns,  of  Leipzic,  performed  some  experiments  on  this  sub- 
ject. Of  twenty-five  attempts  to  convey  erysipelas  by  direct  inoculation  to 
healthy  rabbits,  a  positive  result  was  obtained  in  only  five.  In  all  the  suc- 
cessful cases,  the  inoculated  liquid  contained  bacteria,  and  the  addition  to  it  of 
a  two  to  four  per  cent,  carbolic  acid  solution  rendered  a  previously  active  in- 
oculating fluid  quite  inert.  But  the  presence  of  bacteria,  either  in  the  secre- 
tions or  in  the  tissues  themselves,  is  not  a  constant  feature  in  erysipelas.  It 
is  thus  probable  that  not  every  case  of  erysipelas  is  brought  about  by  the 
migration  of  bacteria  as  such,  and  that  the  advance  of  the  disease  is  not  in  all 
cases  connected  with  the  presence  of  these  micro-organisms.3  According  to 
Koch,  the  distinctive  micro-organism  of  erysipelas  i&"a  bacillus.4 

1  Guv's  Hospital  Reports,  3d  s.,  vol.  xix.  p.  357. 

2  Archiv  f.  experiment.  Pathol,  u.  Pharm.,  Bd.  i.  S.  81. 

3  Edinburgh  Medical  Journal,  vol.  xxv.  p.  666. 

4  Etiology  of  Traumatic  Infective  Diseases,  New  Sydenham  Society's  edition,  1S80,  p.  57- 


168  ERYSIPELAS. 

Whether  the  hypothetical,  specific  contagium  produces  the  symptoms  of 
erysipelas  by  a  direct  and  primary  action  upon  the  blood  and  nervous  system ; 
or  whether  it  acts,  first  of  all,  upon  the  tissue  that  receives  it,  and  only  second- 
arily affects  more  distant  organs  ;  or,  finally,  whether  it  may  and  does,  accord- 
ing to  circumstances,  act  in  both  of  these  ways,  is  still  an  open  question,  and 
is  very  likely  to  remain  unsolved.  Very  probably  the  erysipelatous  poison 
may  enter  the  system,  either  by  a  lesion  of  the  integument  or  through  the 
mucous  membrane  of  the  fauces  and  respiratory  organs,  precisely  as  the  viruses 
of  smallpox,  measles,  and  scarlatina  find  admission.  The  rapidity  with  which 
it  infects  the  blood  and  the  type  of  the  resulting  fever,  will  depend  upon 
several  conditions,  of  which  the  most  influential  is  probably  the  inherent  ac- 
tivity of  the  poison  itself,  and  the  next  is  the  power  of  resistance  possessed  by 
the  patient.  The  latter  again  will  depend  in  part  upon  the  conditions  that 
surround  the  patient,  including  fresh  air,  proper  temperature  and  food,  fatigue, 
cleanliness,  etc. 


The  Causes  of  Erysipelas  as  illustrated  by  the  History  of  Epidemic 
Outbreaks  of  the  Disease. 

The  histories  of  epidemics  of  erysipelas  remove  any  doubts  of  the  septic 
and  constitutional  nature  of  the  disease  that  may  be  suggested  by  a  partial 
study  of  it  in  isolated  medical  and  surgical  cases.  Even  in  the  medical  records 
of  the  latter  part  of  the  eighteenth  century,  it  was  pointed  out  that  erysipelas 
began  in  the  throat ;  and,  although  in  some  cases  it  appears  to  have  been  con- 
founded with  diphtheria,  no  doubt  remains  that  an  erysipelatous  angina  asso- 
ciated with  erysipelas  of  the  skin  prevailed  epidemically  in  Great  Britain 
between  1777  and  1800,  and  subsequently  in  1821,  as  well  as  occasionally  even 
as  late  as  1832.1  Daude,2  in  his  narrative  of  the  epidemics  of  erysipelas  that 
prevailed  on  the  continent  of  Europe,  refers  to  one  that  occurred  in  France  in 
1750,  in  which  the  symptoms  were  "difficult  deglutition,  hoarseness,  swelling 
of  the  neck,  and  the  other  symptoms  of  quinsy,"  as  well  as  to  other  epidemics 
of  the  disease  in  which  pneumonia  or  diarrhoea  existed  as  a  complication.  In 
almost  every  instance,  the  sore  throat  preceded  the  cutaneous  inflammation, 
but  some  examples  of  the  reverse  order  were  met  with.  Daude  describes  the 
disease  as  presenting  the  following  categories:  (1)  Cases  of  erysipelas  com- 
mencing in  the  skin  and  extending  to  internal  parts,  including  the  organs  of 
deglutition  and  respiration,  the  vagina,  and  the  rectum ;  (2)  Cases  beginning 
in  the  throat  or  the  lungs,  and  thence  spreading  to  the  skin  of  the  face,  etc. ; 
(3)  Cases  beginning  in  the  throat  or  other  internal  part,  and  not  involving 
the  skin. 

In  the  United  States,  epidemic  erysipelas  does  not  appear  to  have  been  ob- 
served until  1843  (a  fact  which  of  itself  would  demonstrate  its  specific  origin), 
and  it  continued  to  prevail  until  the  end  of  1847.  Another  circumstance 
which  also  shows  that  it  originated  in  some  special,  atmospheric  cause,  is  that 
it  prevailed  within  definite  although  extensive  limits,  which  may  roughly  be 
indicated  by  the  terms  west  and  northwest  of  the  Apalachian  mountain  range, 
and  extending  from  Lake  Champlain  in  the  northeast,  through  the  States  ot 
New  York,  Michigan,  Indiana,  Missouri,  Mississippi  and  Louisiana,  while  it 
was  almost  unknown  in  southern  New  York,  eastern  Pennsylvania,  and  the 
other  Atlantic  States.  Almost  the  only  exception  to  this  statement  is  the 
occurrence  of  an  epidemic  of  the  disease  at  Bridgeport,  Conn.,  in  1847.3     In 

1  Nunnely  on  Erysipelas.  2  Traite  de  l'erysipelo  tpideniique. 

3  Bennett,  JN.evv  yprjs:  Journal  of  Medicine,  July,  1853,  p.  9. 


HISTORIES   OF   EPIDEMICS   OF   ERYSIPELAS.  169 

the  western  and  southwestern  States,  the  name  usually  given  to  the  affection 
was  "  Black  tongue,"  which  recalled  one  of  its  usual  local  symptoms,  and 
suggested  the  distinctive  type  of  the  fever.  On  studying  this  epidemic  in 
relation  to  the  general  subject  of  erysipelas,  we  find  in  the  succession  of  its 
phenomena  abundant  evidence  of  its  constitutional  nature,  and  hence  of  that 
of  other  forms  of  erysipelas.  For  while,  in  some  cases,  the  attack  was  ush- 
ered in  by  the  simultaneous  appearance  of  the  throat  affection  and  the  general 
febrile  phenomena,  in  many  others  the  constitutional  pyrexial  disorder,  even 
in  an  intense  degree,  preceded  the  anginose  symptoms  by  one  or  more  days, 
and  even  the  glands  of  the  neck  swelled  out  of  all  proportion  to  the  inflamma- 
tion of  the  throat.  The  latter  usually  preceded  the  erysipelatous  inflammation 
of  the  skin,  which,  according  to  some  authorities,  occurred  in  about  one-sixth 
of  the  cases  ;  but  sometimes  the  opposite  course  was  pursued,  and,  as  has  also 
been  observed  in  Europe,  the  inflammation  of  the  skin  was  primary  and  was 
seen  to  invade  the  throat  by  extension  through  the  mouth  or  nostrils. 

The  condition  of  the  throat  was  as  various  as  that  of  the  skin  is  in  the 
several  forms  of  cutaneous  erysipelas.  Sometimes  the  inflammation  was 
superficial,  the  part  of  a  bright  red  color,  and  neither  the  mucous  membrane  in 
general  nor  its  glands  were  much  swollen  ;  but  in  other  cases  the  fauces  and  the 
tongue  were  greatly  swollen  and  purplish ;  and  in  others,  again,  dark  or  ash- 
colored  sloughs  formed  upon  the  roof  of  the  mouth  and  the  soft  palate.  "  The 
tongue  was  apt  to  be  very  much  swollen,  assuming  a  blackish-brown  color, 
and  deglutition  was  almost  impossible,"  says  Sutton,  in  his  description  of  the 
Indiana  epidemic  of  1843.  "  In  most  cases  an  erysipelas  would  commence  at 
the  angle  of  the  mouth  or  nose,  and  spread  over  the  face  and  head.  The  inflam- 
mation of  the  throat  sometimes  passed  down  the  trachea  and  bronchia,  into 
the  nostrils,  frontal  sinuses,  or  antrum  maxillare,  buf  usually  the  throat  became 
well  while  the  erysipelas  was  spreading  over  the  skin."  To  these  particulars 
it  may  be  added  that  the  sloughs  above  mentioned  were  apt  to  be  preceded 
by  bulla?  or  phlyctenre  filled  with  a  serous  and  sometimes  a  bloody  liquid. 
All  who  have  described  this  affection  note  the  great  elongation  and  flaccidity 
of  the  uvula,  and  the  sometimes  enormous  swelling  of  the  lymphatic  glands 
of  the  neck.  In  not  a  few  cases,  stated  at  one-twelfth  of  the  whole,  diffuse 
inflammation  affected  the  connective  tissue  in  the  axilla,  or  below  the  pectoral 
muscles,  sometimes  extending  underneath  the  great  muscles  of  the  back  and 
over  the  entire  trunk,  or  to  two  or  more  limbs,  dissecting  out  the  muscles, 
and  often  terminating  in  gangrene,  with  a  discharge  or  the  artificial  removal 
of  long  shreds  of  dead  connective  tissue  resembling  wet  tow,  such  as  will  pre- 
sently be  described  as  occurring  in  phlegmonous  erysipelas  of  traumatic  ori- 
gin. In  many  of  these  cases,  anginose  symptoms  with  fever  preceded  for 
days,  or  even  weeks,  the  diffused  cellular  inflammation  referred  to.  Accord- 
ing to  the  reporters  of  certain  epidemics,  the  discharged  liquid  was  so  acrid 
"that  the  hardest  steel  was  directly  penetrated  by  it  as  by  nitric  acid."1  In 
the  most  favorable  cases,  when  a  cure  resulted,  adhesions  were  apt  to  form 
between  the  denuded  muscles  and  the  skin,  greatly  and  permanently  restrict- 
ing the  movements  of  the  part. 

In  the  American  as  well  as  in  the  European  epidemics,  the  internal  compli- 
cations formed  a  very  important  element  of  the  disease,  not  only  by  increasing 
its  gravity,  but  also  by  illustrating  its  nature  as  a  blood  disease.  One  of  the 
first  of  its  American  historians,  Sutton,  describes  as  accompanying  the  ery- 
sipelas, a  typhoid  pneumonia,  which  sometimes  was  associated  with  swelling 
of  the  axillary  glands ;  and  he  suggests  that  it  might  be  regarded  as  a  "  pul- 
monic erysipelas."     Ten  years  later  this  account  was  fully  confirmed  by  Ben- 

1  Hall  and  Dexter,  American  Journal  of  tlie  Medical  Sciences,  Jan.  1844. 


170  ERYSIPELAS. 

nett,  who  particularly  noted  the  predominance  of  the  subcrepitant  over  the 
crepitant  rale,  and  who  also  described  the  hurried  and  labored  respiration  of 
the  attack.  By  this  writer  and  by  many  others,  the  complication  of  the  dis- 
ease with  inflammation  of  the  serous  membranes  is  much  dwelt  upon,  espe- 
cially with  that  of  the  pleura,  peritoneum,  and  cerebral  meninges.  They  also 
allude  to  the  pain  of  a  neuralgic  character  accompanying  the  first-named 
affection.  In  a  fatal  case,  complicated  with  pleurisy,  the  softness  of  the  exu- 
dation and  the  presence  of  bloody  serum  are  noted.  Peritonitis,  both  in  the 
puerperal  and  the  non-puerperal  state,  was  recognized  as  the  most  formidable 
expression,  or  complication,  of  epidemic  erysipelas.  In  the  latter,  the  patient 
was  seized  with  pain  in  the  abdomen,  vomiting,  and  diarrhoea,  followed  by 
great  frequency  of  pulse  and  fatal  collapse ;  and  after  death  the  peritoneum 
was  seen  to  be  dusky  and  injected,  while  its  cavity  contained  a  dark  serum 
which  presented  occasional  flakes  of  lymph,  and  exhaled  a  loathsome  smell. 
The  viscera  were  also  darkly  congested  and  softened.  In  the  post-puerperal 
state  the  attack  invariably  commenced  within  forty-eight  hours  after  delivery, 
with  the  same  symptoms  as  in  the  non-puerperal  cases,  and,  with  rare  excep- 
tions, terminated  fatally. 

Having  furnished  this  general  sketch  of  epidemic  erysipelas,  it  may  prove 
instructive  as  well  as  interesting  to  present  some  examples  of  the  associa- 
tion of  the  internal  and  external  manifestations  of  the  disease,  which  may 
serve  to  illustrate  the  essential  unity  of  its  various  types.  To  show  the  growth 
of  knowledge  upon  the  subject,  they  will  be  presented  in  a  nearly  chronologi- 
cal order.  As  late  as  1836,  the  nature  of  erysipelas  was  imperfectly  recog- 
nized, and  a  teacher  as  acute  as  Latham  endeavored  to  explain  its  various 
phases  by  representing  the  "  disease"  as  at  one  time  implicating  the  vascular, 
and  at  another  time  the  nervous  system.  This  ontological  idea  must,  with 
our  present  light,  be  regarded  as  metaphorical,  and  as  expressing  nothing 
more  than  the  fact  common  to  all  acute  febrile  diseases  due  to  blood  poison- 
ing, that  their  phenomena  may,  according  to  the  nature  and  dose  of  the  mor- 
bid poison,  be  either  sthenic  or  typhoid.1 

In  1852,  Blake2  described  the  prevalence  of  erysipelas  of  the  throat  in  California, 
was  attended  in  some  cases  with  fetid  suppuration  of  the  nostrils,  in  others  with  inflam- 
mation of  the  palpebral  conjunctiva,  or  with  a  discharge  of  pus  from  the  ears. 

In  1855,  Todd3  referred  to  a  form  of  erysipelas  beginning  in  and  confined  to  the  pha- 
rynx, in  which,  on  inspection,  there  was  little  swelling  observed,  but  rather  a  dusky  hue 
of  the  mucous  membrane,  and  a  remarkable  loss  of  reflex  excitability.  Deglutition  was 
very  difficult,  and  food  was  very  apt  to  pass  into  the  larynx,  excite  strangling,  and  be 
rejected  through  the  nostrils.  In  the  same  communication4  he  states  that  it  was  probably 
of  this  affection  that  Nicholas,  Emperor  of  Russia,  died,  the  disease  having  been  erro- 
neously stylctl  "  paralysis  of  the  lungs." 

In  1856,  Gubler  went  so  far  as  to  maintain  that  erysipelas  of  the  face  was  usually  a 
propagation  of  the  disease  from  the  pharynx,  although  it  might  pursue  the  opposite 
course  ;  and  Trousseau,  in  a  clinical  lecture,  took  for  his  text  a  case  in  which  the  ery- 
sipelas was  at  first  confined  to  the  fauces  and  submaxillary  glands,  and  only  on  the 
fourth  day  issued  from  the  nostrils,  and  invaded  the  face  and  scalp,  while  it  declined  in 
the  throat.8 

In  1  857,  Forget0  reported  a  case  of  erysipelas  of  the  face  in  which  the  patient  hecame 
convalescent  on  the  eighth  day;  but  directly  afterwards  a  large  abscess  formed  over 
each  parotid  gland,  and  one  of  them  discharged  through  the  auditory  canal,  while  the 
accompanying  symptoms  were  in  a  high  degree  typhoidal. 

In  1858,  Mr.  Bird7  drew  particular  attention  to  the  frequency  with  which  idiopathic 

1  Compare  Latham's  Works,  vol.  ii.  p.  460. 

2  American  Journal  of  the  Medical  Sciences,  October.  1852,  p.  60. 

'  Medical  Times  and  Gazette,  July,  !K">.r»,  p.  28.  '  Ibid  p.  27. 

5  Lectures  on  Clinical  Medicine,  Now  Sydenham  Society's  edition,  vol.  ii.  p.  251. 

''  Bulletin  de  The>apeutique,  t.  liii.  p.  534.  J  Ranking'*  Abstract,  1859. 


HISTORIES   OF    EPIDEMICS   OF    ERYSIPELAS.  171 

erysipelas  made  its  first  appearance,  now  on  the  face,  and  now  in  the  throat,  subse- 
quently spreading  from  the  one  to  the  other  part.  lie  drew  attention  to  the  erysipelas 
of  the  throat  which  takes  its  origin  in  the  wound  of  tracheotomy.  Indeed,  in  not  less 
than  sixty  per  cent,  of  the  cases  of  idiopathic  erysipelas  of  the  face  observed  by  this 
surgeon,  a  ditfused  inflammation  of  the  fauces  occurred  as  a  precursor ;  while  in  trau- 
matic cases  this  local  manifestation  was  rarely  present.  He  very  rationally  suggested 
the  reason  of  this  difference  in  the  following  question  :  "  Is  it  that  the  miasm  in  being 
inhaled  into  the  lungs  makes  a  direct  impression  on  the  throat,  while  in  its  entrance 
into  the  circulation  by  means  of  a  wound  this  mode  of  contact  is  avoided  ?" 

In  1859  and  I860,  Dr.  Todd  again1  noted  the  passage  of  erysipelas  between  the  fauces 
and  the  face,  in  certain  cases  the  nearly  simultaneous  affection  of  both  localities,  and 
the  tendency  of  the  disease  to  cause  oedema  of  the  larynx.  He  also  related  a  case  of 
surgical  erysipelas  of  the  thigh,  which  was  in  process  of  improvement  when  the  patient 
was  attacked  with  severe  dyspnoea  with  bronchial  rales,  and  died  asphyxiated.  On 
examination,  the  lungs  were  found  greatly  congested  and  cedematous,  and  the  bronchia 
choked  with  mucus. 

In  1861,  Dechambre,  describing  the  epidemic  at  Paris  in  the  spring  and  summer 
of  that  year,2  illustrated  on  a  large  scale  the  tendency  of  the  disease  to  occupy  the  mu- 
cous membranes  as  well  as  the  skin.  Affecting  the  face,  it  caused  an  enormous  swelling 
of  the  subcutaneous  tissues,  with  phlyctenre,  abscesses,  and  tumefaction  of  the  lymphatic 
glands.  Often  the  neck  grew  so  thick  and  hard  that  the  veins  were  compressed,  and 
the  mucous  membrane  of  the  mouth  and  fauces  acquired  a  dull,  purple  color;  the  tongue 
was  dry  and  rough  ;  deglutition  was  very  difficult ;  and  delirium,  violent  at  first,  grew 
more  tranquil  as  it  passed  into  coma  vigil,  or  absolute  stupor,  often  ceasing  entirely 
twelve  or  twenty-four  hours  before  death.  In  a  certain  case  the  inflammation  began 
in  the  throat  and  extended  through  both  Eustachian  tubes,  producing  the  characteristic 
pains  of  internal  otitis  ;  then  appeared  in  the  ears  and  spread  upon  the  neck  and  face, 
advancing  from  both  sides  and  meeting  at  the  median  line.  In  another  case,  the 
erysipelas  started  from  the  fauces,  passed  through  the  nostrils,  and  diffused  itself  upon 
the  face. 

In  1863,  a  writer3  pointed  out  the  distinctive  marks  of  erysipelatous  pharyngitis  as 
follows  :  A  crimson  color,  with  cedematous  swelling  extending  rapidly  from  the  uvula 
and  tonsils  to  the  mouth,  posterior  fauces,  and  pharynx,  causing  so  much  swelling  of 
the  latter  as  to  impede  or  prevent  deglutition,  and  of  the  opening  of  the  larynx  as  to 
hinder  respiration  and  to  alter  the  voice  or  occasion  aphonia. 

In  1865,  Dr.  John  Ashhurst,  Jr.,4  published  the  case  of  a  man  who  entered  the 
hospital  for  a  simple  fracture  of  the  metacarpal  bones.  A  fortnight  later  he  was  about 
to  quit  the  hospital,  when  he  was  attacked  with  acute  febrile  symptoms  and  consider- 
able swelling  of  the  fauces,  which  were  mottled  with  yellowish  shreds.  On  the  follow- 
ing day  erysipelas  appeared  upon  the  face,  the  parotid  and  submaxillary  glands  were 
enlarged  and  indurated,  and  the  patient,  falling  into  a  typhoid  state,  died  on  the  ninth 
day.  On  examination,  it  was  found  that  the  erysipelas  extended  through  the  larynx 
and  trachea  into  the  bronchia,  and  at  the  lower  part  of  the  trachea  was  a  small  ulcer. 
The  heart  contained  large  fibrinous  clots,  but  elsewhere  the  blood  was  exceedingly 
black,  and  of  about  the  consistence  of  molasses. 

In  the  following  instance,  the  progress  of  the  disease  was  the  reverse  of  that  de- 
scribed in  the  last  case.  In  1864,  Simon  published5  an  account  of  a  girl  affected  with 
erysipelas  of  the  scalp,  face,  and  neck  ;  she  then  became  unable  to  open  her  mouth, 
swallowed  with  difficulty,  and  grew  aphonic.  On  the  tenth  day  she  died  comatose. 
On  examination,  the  mouth  was  pale,  but  the  fauces  were  of  a  deep  purple  color,  the 
follicles  enlarged,  and  the  mucous  membrane  softened.  The  same  dark  hue  prevailed 
throughout  the  air  passages  which  were  dry  and  free  from  exudation.  The  lungs  were 
greatly  engorged,  as  were  also  the  membranes  of  the  brain. 

In  1866    Dr.  "W.  J.  Wilson6  described  a  case  which  began  as  sore  throat,  with  pain- 

1  Clinical  Lectures.  2  Gazette  Hebdomadaire,  Juillet,  1861. 

3  American  Medical  Times,  April,  1863.  p.  196. 

4  American  Journal  of  the  Medical  Sciences,  July,  1865,  p.  103. 

5  Bulletins  et  Memoires  de  la  Societe  Medicale  des  Hopitaux  de  Paris,  2e  seVie  t.  i.  p.  199. 

6  American  Journal  of  the  Medical  Sciences,  July,  1866,  p.  275. 


172  ERYSIPELAS. 

ful  deglutition,  and  swelling  of  one  tonsil  and  of  the  neck  externally.  These  symptoms, 
subsiding,  were  followed  by  laryngeal  obstruction  which  required  tracheotomy.  The 
wound  was  attacked  with  erysipelas  which  spread  over  the  skin,  but  the  patient  made 
a  good  recovery. 

Not  to  prolong  unduly  this  enumeration,  a  case  of  more  recent  occurrence  may  be 
noticed.  Strauss1  relates  the  history  of  a  man  who,  during  convalescence  from  an  attack 
of  erysipelas  of  the  face  and  scalp,  was  seized  with  pain  and  swelling  in  the  right  side 
of  the  throat,  while  the  corresponding  lung  was  dull  on  percussion,  and  gave  a  crepi- 
tant rale  in  the  lower  lobe.  But  there  was  neither  chill,  cough,  nor  expectoration.  In 
four  days  death  occurred  ;  the  pharynx  and  right  bronchia  were  congested,  but  con- 
tained no  fibrinous  mould  or  filaments,  and  the  alveoli  were  crowded  with  leucocytes. 

With  these  examples  before  the  reader,  the  hearing  of  the  following 
remarks  will  be  more  apparent  and  intelligible.  As  long  as  erysipelas  was 
regarded  as  merely  an  inflammation  of  the  skin,  the  unity  of  the  disease 
and  its  dependence  upon  a  special  poison  were  not  readily  recognized.  Hence 
the  artificial,  although  apparently  practical,  disjunction  of  medical  and  sur- 
gical erysipelas,  which  deluded  learners,  misled  practitioners,  and  em- 
barrassed authors.  Continued  observation,  however,  showed  that  the  disease 
sometimes  arose  idiopathically,  and  was  sometimes  of  traumatic  origin,  and 
that  in  both  cases  it  could,  on  the  one  hand,  be  traced  to  certain  definite 
causes,  such  as  putrefaction,  and  yet  might  fail  to  occur  when  such  causes 
existed  in  great  activity,  or  might  prevail  fatally  where  no  similar  conditions 
could  be  detected.  From  such  facts  the  rational  conclusion  could  only  be 
that  beneath  all  the  immediate  and  apparent  causes  of  the  disease,  lay  certain 
essential  conditions  of  its  production.  But  the  time  was  not  yet  ripe  for  a 
demonstration  of  this  proposition.  Later,  it  began  to  be  assumed  that  iti  all 
cases  of  erysipelas  a  positive  lesion  must  exist  to  admit  the  poison,  and,  very 
frequently,  minute  inspection  revealed,  upon  the  skin,  a  pimple,  a  scratch,  or 
a  patch  of  herpes  or  eczema,  which  formed  the  starting-point  of  the  erysipe- 
latous inflammation,  and  sometimes  an  analogous  lesion  of  the  mouth  or 
throat.  However  necessary  it  may  be,  and  probably  is,  that  a  lesion  of  the 
skin  should  exist  before  erysipelatous  infection  can  take  place  through  that 
channel,  for  the  sound  skin  is  an  exhaling  and  not  an  absorbing  organ, 
the  reverse  is  true  of  the  mucous  membranes,  which  are  all,  in  various 
degrees,  absorbing  surfaces.  If,  therefore,  erysipelas  is  disseminated  by  a 
materies  morbi,  it  is  only  in  accordance  with  a  general  law  that  it  should 
frequently  make  its  first  impression  upon  the  mouth,  throat,  and  nostrils,  as 
the  poisons  of  smallpox,  scarlet  fever  and  measles,  usually  do;  for  if  the  poi- 
son is  inhaled,  it  necessarily  comes  first  in  contact  with  these  parts,  and  in 
its  most  concentrated  form. 

In  traumatic  or  surgical  erysipelas,  the  mode  of  entrance  of  the  poison 
into  the  system  hardly  needs  demonstration,  for  it  is  in  wounds  of  all  grades, 
from  the  most  trifling  abrasion  to  the  most  extensive  removal  of  the  integu- 
meul  by  accident  or  by  the  surgeon's  knife,  that  the  starting-point  of  the 
disease  is  to  be  sought.  Its  characteristic  phenomena  are,  indeed,  not  always 
first  manifested  at  that  point,  for,  as  is  more  particularly  set  forth  elsewhere, 
remote  lymphatic  ganglia  are  quite  frequently  the  first  parts  to  become 
swollen  and  painful;  and  in  other  cases,  a  febrile  movement  of  a  seemingly 
idiopathic  nature  sets  iii  before  the  local  phenomena,  whether  traumatic 
inflammation  or  glandular  swelling,  are  developed.  It  is  evident,  then,  that 
it  is  not  erysipelas  as  ;m  inflammation,  which  alone  occasions  redness  over  the 
lymphatic  vessels  and  swelling  of  the  corresponding  glands,  but  that  some- 
thing is  absorbed  03'  those  vessels  from  an  infected  wound  or  mucous  mem- 

'  Medical  News,  Feb.  1880,  p.  93. 


CONNECTION    OF    EPIDEMIC    EKYSIPELAS    WITH    PUERPERAL    FEVER.  173 

brane,  viz.,  the  specific  poison  of  the  disease.  Later,  the  morbid  process 
takes  on  that  peculiar  form  of  inflammation  which  is  known  as  erysipelatous; 
but  it  is  important  to  bear  in  mind  that  the  local  phenomena,  and  especially 
the  primary  ones,  are  not  necessarily  proportioned  to  the  general  symptoms. 
A  severe,  and  even  a  fatal  erysipelas  may  follow  infection  through  a  trifling 
wound  in  the  skin,  or  a  short  exposure  to  an  erysipelatous  atmosphere,  just 
as  a  confluent  variola  may  result  from  a  like  exposure  to  the  contagion  of 
smallpox.  The  specific  virulence  of  the  poison  is,  indeed,  one  element  of  its 
power,  but  the  gravity  of  its  effects  also  depends  in  no  small  degree  upon 
the  greater  or  less  susceptibilitj-  and  power  of  resistance  of  the  patient. 


Connection  of  Epidemic  Erysipelas  with  Puerperal  Fever. 

The  prevalence  of  erysipelas  and  puerperal  fever  at  the  same  time,  and  in 
the  same  places,  could  hardly  have  failed  to  attract  the  attention  of  observant 
physicians  at  all  times,  yet  the  intimate  relations  between  the  two  affections 
appear  to  be  of  comparatively  recent  discovery.  Perhaps,  even  now,  they 
are  either  quite  unknown  to  many,  or  else  their  significance  is  misappre- 
hended. It  is  very  desirable,  if  these  diseases  stand  related  to  each  other  as 
cause  and  effect,  or,  again,  as  common  effects  of  the  same  cause,  that  it  should 
be  universally  known  both  for  the  sake  of  removing  the  causes  which  are 
common  to  both  of  them,  and  for  guiding  the  treatment  demanded  by  the 
analogy,  if  not  identity,  of  their  nature. 

The  earliest  opinion  affirming  a  relationship  between  the  two  diseases,  is 
ascribed  to  Pouteau,  who  in  1750  expressed  his  opinion  that  the  puerperal 
fever  which  then  prevailed  in  Paris  was  an  erysipelas  of  the  peritoneum.1 
From  that  time  until  the  fourth  decade  of  the  present  century,  the  subject 
does  not  appear  to  have  attracted  much  attention ;  but  in  1842,  Mr.  Storrs,  of 
Leeds,  England,  reported  that  having  attended  a  case  of  gangrenous  erysip- 
elas of  the  foot  and  leg,  in  which  several  abscesses  formed,  which  he  opened, 
he  delivered  several  women  in  succession,  all  of  whom  were  attacked  with 
puerperal  fever  and  died.2  In  the  following  year,  Dr.  0.  W.  Holmes  related 
the  history  of  a  local  epidemic  of  puerperal  fever,  which  had  its  origin  in 
the  autopsy  of  a  case  which  appears  to  have  been  one  of  gangrenous  erysip- 
elas of  the  leg.  Several  cases  of  erysipelas  occurred  in  the  house  where  this 
person  died;  the  nurse  who  laid  out  the  body  of  one  of  the  puerperal  patients 
died  of  sore  throat  and  erysipelas  of  the  skin;  and  another  nurse  met  Avith 
a  similar  fate,  without  presenting,  however,  any  sign  of  cutaneous  erysipelas.3 
About  the  same  time  puerperal  fever  and  erysipelas  prevailed  epidemically 
in  Cincinnati,  Ohio,  and  Dr.  Minor  of  that  city  distinctly  traced  the  propa- 
gation of  each  disease  by  the  other,  and  from  one  patient  to  another  In- 
direct communication,  including  the  production  of  erysipelas  in  the  infants 
of  mothers  who  had  been  attacked  by  puerperal  fever.4  In  Missouri,  the 
same  coincidence  and  transmission  of  the  diseases  were  frequently  remarked, 
by  Dr.  G-.  W.  Sickles  among  others.5 

In  1850,  a  narrative  was  furnished  by  Hill6  which  illustrates  the  subject 
further : — 

1  Ranking's  Half-yearly  Abstract,  1859,  p.  84. 

2  Provincial  Medical  and  Surgical  Journal,  April,  1842. 

3  New  England  Quarterly  Journal  of  Medicine  and  Surgery,  April,  1S43. 
*  Erysipelas  and  Childbed  Fever,  1S47. 

5  St.  Louis  Medical  and  Surgical  Journal,  vol.  viii.  p.  1. 

6  Monthly  Journal  of  Medical  Science,  March,  1850,  p.  299. 


174  ERYSIPELAS. 

A  carpenter  wounded  his  hand  while  making  a  coffin,  and,  on  placing  the  corpse  in 
it,  some  fluid  from  the  body  came  in  contact  with  the  wound.  He  had  a  severe  attack 
of  erysipelas,  which  he  communicated  to  his  wife.  Meanwhile,  their  daughter,  seven 
months  pregnant,  who  had  come  home  to  be  confined,  was  seized  with  fever.  The  phy- 
sician, after  visiting  this  woman,  went  to  attend  another  in  labor.  The  following  day 
the  carpenter's  daughter  gave  birth  to  a  dead  child,  and  died  of  puerperal  fever.  The 
physician  did  not  return  to  the  other  lying-in  patient,  who,  however,  suffered  an  attack 
of  puerperal  fever,  but  recovered.  In  the  practice  of  the  same  physician,  a  girl  suffer- 
ing from  erysipelas  of  the  face  was  attended  by  her  mother  then  about  to  be  confined. 
The  child  was  born  with  erysipelas  and  died.  The  midwife  immediately  afterwards 
attended  a  healthy  girl  in  labor,  who  also  had  a  mild  attack  of  puerperal  fever,  but  her 
father,  who  waited  on  her  assiduously,  was  affected  with  erysipelas  of  the  throat  of  which 
he  died  on  the  ninth  day.  Four  other  persons  who  assisted  in  nursing  some  of  these 
patients  were  attacked  with  erysipelas,  but  recovered. 

During  a  local  outbreak  of  erysipelas  in  Platte  County,  Missouri,  Dr.  Rid- 
ley reports1  that  while  attending  cases  of  this  disease,  he  acted  as  accoucheur 
to  three  ladies  within  the  space  of  one  week,  all  of  whom  were  attacked  with 
puerperal  fever  and  died.  These  were  the  only  cases  in  the  locality.  In 
1852,  an  epidemic  of  malignant  erysipelas  occurred  in  New  Castle,  Pa. 
While  attending  one  of  the  cases,  Dr.  Leasure  delivered  a  healthy  woman 
of  her  seventh  child  after  a  natural  labor.  She  died  on  the  fourth  day  of 
typhoid  metro-peritonitis,  and,  after  a  like  interval,  her  infant  died  of  erysipe- 
las. A  second  case  occurred  under  identical  circumstances,  with  like  results 
for  both  mother  and  child,  and  the  nurse  also  suffered  from  erysipelas,  and 
barely  escaped  with  her  life.  A  third  puerperal  case  of  the  same  physician 
presented  a  similar  history,  as  did  two  other  cases  under  the  care  of  another 
practitioner  who  had  also  been  treating  erysipelas.  Both  physicians  then 
abstained  from  attending  any  more  lying-in  women,  and  no  further  cases  of 
puerperal  fever  occurred.  Dr.  Leasure  concludes  his  narrative  with  these 
words :  "  My  cases  of  childbed  fever  were  neither  more  nor  less  than  cases 
of  malignant  erysipelas,  fatally  modified  by  the  condition  of  the  patients,  and 
the  manner  of  introducing  the  morbid  poison.2  About  the  same  time,  Dr. 
Todd,  in  England,  said  of  puerperal  peritonitis,  it  is  "  a  disease  which  I  be- 
lieve is  really  of  an  erysipelatous  nature.'"3  Dr.  Dutcher  related  several  cases 
illustrative  of  this  subject,  of  which  the  following  is  very  significant: — 4 

A  physician  while  attending  a  case  of  phlegmonous  erysipelas  was  called  to  a  case  of 
confinement.  The  patient  died  of  puerperal  fever.  In  the  course  of  four  weeks  he 
attended  seven  cases  of  labor,  and  in  every  instance  the  mother  died  of  puerperal  fever, 
while  the  children  perished  with  general  cutaneous  erysipelas.  Finally,  the  physician 
was  himself  attacked  with  erysipelas  of  the  hand,  which  nearly  proved  fatal. 

In  Philadelphia  the  case  is  well  remembered  of  a  physician  in  extensive 
practice;  who  had  ninety-five  cases  of  puerperal  fever  in  rapid  succession, 
while  none  were  occurring  in  the  practice  of  the  neighboring  practitioners  ; 
and  of  the  children  born  in  these  cases  no  less  than  fifteen  died  of  erysipelas. 
In  1857,  Dr.  Duncan,  of  York,  Pa.,  related  the  case  of  a  lady  in  whom  an 
attack  of  puerperal  fever  occurred  simultaneously  with  erysipelas  of  the  face, 
while  her  infant  suffered  from  erysipelas  of  the  umbilicus.8 

In  lH(i2,  a  memoir  upon  this  subject  was  published  in  Paris  by  Pihan- 
Dul'cillay,6  who  clearly  demonstrated  the  relations  of  the  two  diseases  to 

1  New  York  Journal  of  Medicine,  vol.  x.  p.  41,  1853. 

2  American  Journal  of  the  Medical  Sciences,  January,  1856,  p.  45. 

3  Medical  Times  and  Gazette,  July,  1855,  p.  28. 

4  American  Journal  of  the  Medical  Sciences,  January,  1856,  p.  99. 
E  North  American  Medico-Chirurgical  Review,  vol.  i.  ]>.  31. 

6  L'Uirion  Mediuale,  and  American  Medical  Times,  vol.  v.  p.  60. 


CONNECTION    OF    EPIDEMIC    ERYSIPELAS    AVITII    PUERPERAL    FEVER.  175 

one  another  by  numerous  examples,  domestic  and  foreign.  lie  maintained 
that  there  were  eases  in  which  the  same  cause  seemed  to  engender  both  diseases, 
which  differed  from  one  another  only  in  their  subordinate  characters,  but  were 
identical  in  their  nature ;  as  appears  when,  under  the  same  general  conditions, 
erysipelas  ravages  surgical  wards,  and  puerperal  fever  lying-in  hospitals  or 
wards.  If  the  conjunction  were  rare,  it  might  be  viewed  as  a  simple  coinci- 
dence, but  its  frequent  repetition,  if  not  uniform  occurrence,  and  that  not  in 
one  country  alone,  but  in  Europe  and  America  alike,  leaves  no  rational  doubt 
that  an  intimate  relationship  exists  between  the  two  diseases.  Of  the  two, 
the  primary  affection  is  sometimes  erysipelas  and  sometimes  puerperal  fever, 
and  each  has  the  power  of  generating  the  other.  A  very  striking  illustra- 
tion of  the  less  usual  of  these  reciprocal  influences  is  related  by  this  author: — 

A  fatal  epidemic  of  puerperal  fever  occurred  in  the  lying-in  ward  of  a  general  hospi- 
tal. After  a  time,  the  remaining  and  incoming  women  who  were  about  to  be  confined, 
were  transferred  to  a  remote  ward,  which,  until  then,  had  been  used  for  patients  with 
diseases  of  the  skin,  while  the  latter  were  moved  into  the  late  obstetrical  ward,  after  it 
had  been  thoroughly  cleansed.  Thenceforth  the  puerperal  fever  ceased,  but  a  grave 
epidemic  of  erysipelas  broke  out  among  the  new  tenants  of  the  obstetrical  ward,  attack- 
ing them  without  regard  to  the  nature  of  their  cutaneous  disease,  their  constitution,  or 
their  general  health. 

An  analogous  illustration  is  furnished  by  Trousseau.1  An  epidemic  of  puerperal 
fever  desolated  the  Maternity  Hospital,  and,  when  the  authorities  felt  compelled  to  re- 
move the  pregnant  women  to  other  hospitals  to  be  confined,  erysipelas  there  broke  out  in 
a  severe  form  in  a  great  many  of  the  surgical  services,  among  those  who  had  wounds. 

It  is  worthy  of  remark  that  in  certain  epidemics  of  erysipelas,  and  notably 
in  that  of  Paris  in  1861,  to  which  reference  has  just  been  made,  a  morbid 
change  in  the  blood  was  manifested  by  certain  prevalent  disorders.  Gangrene 
frequently  occurred,  which  was  apparently  not  produced  by,  or  proportionate 
to,  the  tension  of  the  erysipelatous  skin  ;  and,  in  like  manner,  boils  and  car- 
buncles formed,  which  were  not  at  all  confined  to  the  seats  of  erysipelas,  and 
which,  therefore,  must  have  originated  in  a  special  condition  of  the  blood. 
A  further  and  still  more  curious  fact  in  this  relation,  is  that  many  persons 
suffered  from  such  affections  who  had  not  erysipelas,  although  they  frequently 
occupied  the  same  house  or  lodging  with  those  who  were  laboring  under  that 
disease.  It  is  of  especial  interest,  also,  that  during  this  epidemic  not  only 
did  puerperal  fever  prevail,  but  that  in  not  a  few  cases  pus  formed  in  the 
articulations  and  in  the  serous  cavities  of  the  trunk.2 

Retzius  has  given  the  history  of  puerperal  fever  as  it  occurred  in  the  Lying- 
in  Hospital  of  Stockholm.  It  began  in  1858,  and  grew  more  severe  in*18o9 
and  1860,  so  that  the  hospital  became  crowded,  and,  "  as  a  consequence,"  it 
is  stated,  "  erysipelatous  inflammations  soon  manifested  themselves,  although 
no  analogous  disease  existed  in  the  town,  and  nothing  in  the  condition  of  the 
individual  patients  afforded  any  explanation  of  their  being  attacked."3 

The  following  instance  illustrates  the  dependence  of  erysipelas  and  puerpe- 
ral fever  upon  the  same  essential  cause  : — 

Dr.  Cox  states  that  a  physician  having  bled  an  erysipelatous  patient,  soon  afterwards 
used  the  same  lancet  to  bleed  a  man  who  had  been  hurt  by  a  fall,  and  also  a  woman  in 
labor.     The  man  was  attacked  with  phlebitis  and  the  woman  with  puerperal  fever.4 

To  pass  over  a  period  during  which  the  instructive  nature  of  these  and 
many  analogous  instances,  seems  to  have  been  forgotten  or  neglected,  only  one 

1  Lectures  on  Clinical  Medicine,  vol.  ii. 

2  Dechambre,  Gazette  Hebdomadaire,  Juillet,  1861,  p.  476. 
8  Medical  Times  and  Gazette,  April,  18(32,  p.  383. 

*  American  Medical  Times,  April,  1803,  p.  198. 


176  ERYSIPELAS. 

or  two  additional  illustrations  of  the  important  truth  they  teach  will  be  ad- 
duced. In  1877,  Dr.  Atthill1  furnished  the  history  of  a  local  epidemic  of 
erysipelas,  which  he  summarized  as  follows :  "  Of  ten  (puerperal)  patients 
admitted  into  a  hospital,  of  which  the  sanitary  condition  had,  previous  to 
the  admission  of  a  case  of  erysipelas,  been  most  excellent,  nine  were  attacked 
with  illness  more  or  less  severe,  and  one  died ;  the  only  one  who  escaped 
being  a  case  of  abortion." 

Dr.  Thomas  H.  Buckler  has  stated2  that  "  on  three  several  occasions,  during 
nine  years,  a  single  case  of  erysipelas  admitted  into  the  wards  of  the  Balti- 
more City  and  County  Almshouse  Hospital,  was  the  starting-point  for  the 
spread  of  its  poison  to  all  the  medical  and  surgical  wards  to  such  a  degree 
that  the  most  trivial  operations  had  to  be  avoided,  and  even  the  slightest 
scratch  on  the  skin  was  likely  to  take  on  erysipelas,  followed  in  some  instances 
by  phlebitis  and  pyaemia.  At  last  the  poison  reached  a  lying-in  ward,  more 
remote  than  the  others  from  the  sources  of  infection,  with  invasion  so  fatal, 
that,  after  a  time,  for  a  woman  to  be  delivered  there  was  certain  death." 


Morbid  Anatomy  of  Erysipelas. 

The  most  prominent  lesion  of  erysipelas  is  an  exudative  inflammation  of 
the  skin,  which  is  usually  seated  in  the  thickness  of  the  derm  and  in  the  sub- 
cutaneous connective  tissue,  but  which  is  often  confined  to  the  layers  of  the 
skin  immediately  beneath  the  epidermis.  The  exudation  is  not  merely  sero- 
fibrinous ;  it  contains  a  large  number  of  white  corjmseles,  which  have  mi- 
grated through  the  walls  of  the  bloodvessels.  In  cases  which  tend  towards 
resolution,  they  disintegrate  and  are  reduced  to  minute  granular  particles, 
which  are  then  absorbed.  Drs.  Moxon  and  Goodhart3  found  in  the  blood 
of  several  persons  affected  with  traumatic  erysipelas,  an  increase  in  the  pro- 
portion of  white  corpuscles  ;  but  in  others  this  condition  did  not  exist.  Dr. 
W.  jSTorton  Whitney4  states  that  in  severe  cases  the  proportion  of  the  white 
corpuscles  is  increased ;  to  one  in  fifteen  in  one  case,  and  to  one  in  thirty  in 
another,  and  generally  in  proportion  to  the  rise  in  temperature.  In  severe 
cases  the  red  corpuscles  run  together,  their  edges  are  ill-defined,  and  they  look 
like  streams  of  yellow  fluid  crossing  the  field  of  the  microscope.  They  also 
become  more  rapidly  crenated  than  in  healthy  blood,  showing  a  marked  ten- 
dency, in  severe  cases,  and  especially  when  the  temperature  is  high,  to  adhere 
to  one  another  in  masses,  and  not  in  rolls.  In  a  case  of  Kollman,  of  Leipsic,5 
in  which  repeated  hemorrhages  from  the  bowels  took  place,  fatally  exhaust- 
ing the  patient,  it  is  probable  that  such  blood-changes  existed  in  a  high  de- 
gree. To  them  also  may  be  attributed  the  altered  action  of  the  heart,  and 
the  hsemic  murmurs  heard  during  life,  and  more  immediately  the  fatty  or 
granular  change  sometimes  found  in  the  cardiac  muscles. 

In  1862,  it  was  related  by  Pihan-Dufeillay,  that  enlargement  of  the  sjrteen 
occurred  during  the  then  recent  epidemic  at  the  St.  Louis  Hospital  (Paris); 
and  in  1873,  Friedreich  stated  that  in  ordinary  facial  erysipelas  he  seldom 
looked  in  vain  lor  enlargement  of  the  spleen,  adding  that  the  organ  fre- 
quently attained  such  a  size  as  to  project  below  the  border  of  the  ribs.  He 
refers  particularly  to  a  case  of  floating  spleen  in  which,  during  the  progress 
of  the  erysipelatous  attack,  successive  changes  in  the  size  of  the  organ  could 

'  Obstetrical  Journal  of  Great  Britain,  June,  1877. 

2  Boston  Medical  ami  Surgical  Journal,  October,  1880,  p. '418. 

3  Guy's  Hospital  Reports,  :»1  s.  vol.  xx.  p.  240. 

4  Inaugural  Thesis,  University  of  Pennsylvania,  1881. 
6  Archiv  d.  lloilkunde,  Band  xi.,  S.  398. 


SYMPTOMS    OF   ERYSIPELAS.  177 

be  accurately  estimated.  The  tumor  sometimes  continued  even  for  a  fort- 
night after  the  subsidence  of  the  febrile  symptoms.  This  was  particularly 
noticed  in  erysipelas  of  the  scalp.1 

Even  in  cases  presenting  brain  symptoms,  whether  active  or  passive,  no 
cerebral  lesions  corresponding  to  them  are  found ;  no  exudation  of  lymph, 
and  not  even  a  large  effusion  of  serum ;  but  the  veins,  both  of  the  meninges 
and  of  the  brain,  are  sometimes  engorged  with  blood.  In  erysipelas  of  the 
throat  and  bronchia,  the  mucous  membrane  of  these  parts  is  apt  to  be  darkly 
congested  and  coated  with  tenacious  mucus ;  occasionally  ulcers  are  found 
upon  it.  They  have  also  been  met  with  in  the  intestinal  canal.  Larcher2  met 
with  them  near  the  opening  of  the  ductus  communis  into  the  duodenum,  or 
on  the  opposite  surface.  The  ulcers  were  about  the  size  of  a  split  pea,  and 
did  not  penetrate  the  mucous  coat.  The  analogy  of  these  ulcers  with  those 
that  have  been  found  after  burns  of  the  skin,  and  also  after  scarlatina,  is  in- 
teresting. Malherbe3  met  with  such  ulcers  in  the  jejunum  and  ileum;  but 
they  were  not  seated  in  the  glands. 

In  many,  if  not  in  most  cases,  the  lymphatic  vessels  and  (/lands  are  in- 
flamed, or  at  least  structurally  altered,  and  the  veins  may  be  the  seat  of  a 
similar  change.  This  may  lead  to  coagulation  of  the  blood  in  the  veins 
(thrombosis),  and  the  clots  so  formed  may  be  carried  into  the  vessels  of  the 
lungs,  constituting  embolism  in  those  organs.  Or  the  coagulation  may  obstruct 
an  artery,  and  lead  to  gangrene  of  the  parts  beyond.  Such  accidents  appear  to 
be  more  frequent  in  persons  of  feeble  constitution  or  impaired  physical  con- 
dition than  in  those  of  average  health.  The  local  lesions  found  in  fatal  cases 
of  erysipelas  consist  of  an  infiltration  of  the  connective  tissue  with  a  sero- 
purulent  fluid,  which  renders  the  parts  soft  and  pulpy,  and  dissects  out,  as  it 
were,  the  muscles,  bloodvessels,  and  nerves.  The  parotid  gland  may  be  quite 
disorganized  by  purulent  infiltration  in  cases  of  facial  erysipelas,  and  the 
periosteum  of  the  ramus  of  the  lower  jaw  may  be  separated  from  the  bone. 
The  small  muscles  are  often  reduced  to  a  pulp,  and  the  lymphatic  glands  are 
enlarged  and  suppurating.  Similar  destructive  effects  are  observed  in  cases  of 
phlegmonous  erysipelas  of  the  extremities. 


Symptoms  or  Erysipelas. 

Like  other  diseases  in  which  the  local  phenomena  are  subordinate,  although 
essentially  due,  to  a  vice  of  the  system,  the  first  symptoms  of  erysipelas 
depend  upon  the  condition  of  the  blood.  The  material  cause  of  the  disease, 
circulating  through  the  system,  occasions  phenomena  analogous  to  those 
which  introduce  other  febrile  affections.  These  phenomena  include  general 
discomfort,  muscular  aching,  pain  in  the  head,  loss  of  appetite,  a  chill,  and, 
above  all,  nausea,  with  a  bitter  taste  in  the  mouth,  and  vomiting,  which  is 
often  bilious.  Sometimes,  a  convulsion  is  among  the  earliest  phenomena  of 
the  affection.  ^  The  chill  is  apt  to  be  prolonged  and  severe,  and  may  often  lie 
taken  as  an  indication  of  the  gravity  of  the  subsequent  attack.  It  is  fol- 
lowed by  fever  proportioned  in  severity  to  the  chill,  and  the  temperature 
may  rise  in  a  few  hours  to  104°  F.,  or  even  higher.  If  the  patient  is  already 
suffering  from  fever,  these  phenomena  may  not  be  present,  or  the  rise  of  tem- 
perature may  be  unnoticed.  The  pulse  becomes  frequent,  and  is  usually  full 
and  strong,  especially  in  cases  which  are  rapidly  developed  and  in  previously 

1  German  Clinical  Lectures,  New  Sydenham  Society's  edition,  2d  series,  p.  8. 

2  Archives  generates  de  Medecine,  Dec.  1864,  p.  689. 
8  Ibid.,  Dec.  1865,  p.  725. 

VOL.  I. — 12 


178  ERYSIPELAS. 

lieal thy  persons.  The  fever,  however,  usually  presents  a  daily  morning 
remission.  The  tongue  becomes  rapidly  covered  with  a  yellowish,  thick,  and 
pasty  coating.  Even  yet  the  place  of  entrance  of  the  poison  into  the  system 
may  betray  no  sign  of  its  passage,  while  the  lymphatic  ganglia  through 
which  it  has  passed  grow  tender,  swollen,  and  it  may  be  red.  In  other 
cases,  however,  but  in  a  relatively  small  number,  the  ganglionic  inflamma- 
tion appears  later  than  the  local  evidences  of  erysipelas.  It  is  important  to 
observe  that  not  only  does  the  lymphatic  tenderness  and  swelling,  as  a  rule,\ 
precede  the  inflammation  of  the  skin,  but  that  it  may  even  do  so  for  several 
hours  or  even  days.  Indeed,  an  interval  of  three  or  even  of  six  days  has 
been  observed  between  the  two  events.  This  familiar  clinical  fact  disposes 
readily  of  the  notion  that  erysipelas  is  merely  a  dermatitis,  and  that  the 
constitutional  symptoms  are  due  to  that  inflammation  and  proportioned  to 
its  severity.  They  rather  bear  to  the  local  affection  a  relation  analogous 
to  that  between  smallpox  and  inoculation,  or  between  vaccinia  and  vacci- 
nation. 

In  the  part  about  to  be  invaded  by  erysipelas,  a  sense  of  tightness  is  first 
perceived,  accompanied  with  itching  and  burning  heat,  and  followed  by  a 
steady  pain  which  grows  worse  at  night  and  when  the  skin  is  touched.  At 
the  same  time,  or  soon  after  the  pain  is  felt,  usually  in  from  one  to  three 
daj*s  after  the  occurrence  of  the  initial  symptoms,  a  blush  appears  upon  the 
skin,  and  gradually  deepens  from  a  rose  to  a  deep  crimson  color,  or,  in  cases 
of  a  low  type,  to  a  still  darker  shade,  while  it  extends  in  every  direction 
around  the  point  of  origin;  and  in  the  same  degree  the  skin  swells,  grows 
tense,  smooth,  and  shining,  and  the  redness  and  swelling,  whether  presenting 
a  curved  or  an  angular  outline,  are  bounded  by  an  abrupt  elevation  or  ridge 
which  can  be  both  seen  and  felt  as  they  tend  to  invade  more  and  more  of  the 
sound  skin.  In  persons  of  fair  complexion,  the  contrast  between  the 
inflamed  and  the  adjacent  sound  skin  is  very  striking,  and  the  former  gives 
to  the  finger  an  impression  of  roughness  which  is  due  to  the  distended 
papillae  of  the  derm,  and  to  the  minute  vesicles  which  form  upon  its  surface. 
The  erysipelatous  swelling  is  greatest  where  the  subcutaneous  connective 
tissue  is  most  abundant,  and,  when  it  affects  the  face,  the  eyelids  cannot  be 
opened,  the  nostrils  are  obstructed,  and  even  the  jaws  can  be  but  slightly 
separated  from  one  another.  In  no  other  disease,  except  smallpox,  are  the 
natural  features  so  completely  deformed.  When  a  limb  is  involved,  it  is  so 
heavy,  stiff,  and  painful  on  motion,  that  it  is  instinctively  kept  at  rest.  The 
swollen  part  does  not  usually  pit  on  pressure,  but  is  tense  and  hard ;  but  in 
certain  Bluggish  forms  of  the  disease  the  skin  does  not  resist  pressure,  and 
has  a  boggy  feel.  Besides  the  face,  the  parts  most  liable  to  extreme  swelling 
arc  the  genital  organs  in  either  sex.  The  tendency  of  the  inflammation  is  to 
extend,  not  always  steadily  and  uniformly,  but  by  fits  and  starts,  and  each 
new  exl ension  is  accompanied  with  an  increase  of  the  fever.  Nor  does  it 
usually  spread  equally  in  all  directions  from  the  place  of  starting,  but  gene- 
rally tends  from  points  on  the  extremities  towards  the  trunk,  and  from 
the  lace  towards  the  scalp ;  it  may  also  pursue  a  linear  path,  or  break  out 
freshly  at  one  or  more  remote  points  (Wandering  Erysipelas).  This  is  more 
common  in  surgical  than  in  medical  cases.  In  the  latter,  there  is  a  very 
singular  peculiarity  relating  to  the  point  at  which  the  inflammation  com- 
mences. In  the  v;ist  majority  of  eases,  the  eruption  first  appears  at  the  root 
of  the  nose,  and  next  in  order  upon  the  cheek  or  the  car.  In  old  persons, 
especially  such  as  have  varicose  veins,  it  is  apt  to  attack  the  legs,  but  with- 
out presenting,  as  a  rule,  very  acute  phenomena.  It  has  been  remarked  that 
the  chin  is  very  rarely  involved,  even  in  eases  of  erysipelas  in  which  the 
eruption  occupies  the  rest  of  the  face  and  the  scalp.  ^ 


SYMPTOMS    OF   ERYSIPELAS.  179 

Iii  surgical  erysipelas,  the  local  inflammation  ordinarily  and  evidently 
begins  at  a  wound,  which  always  becomes  dry,  and  of  a  dull  color;  but  when 
the  disease  prevails  in  a  hospital,  some  other  part,  and  especially  the  face, 
may  be  the  first  to  suiter.  The  general  appearance  of  the  eruption  has 
already  been  described,  but  it  may  here  be  added  that  wherever  it  occurs, 
except  upon  the  scalp,  there  may  also  be  present  true  vesicles,  phlyctense,  or 
blebs,  which  are  filled  with  a  thin  and  milky  serum  in  cases  of  moderate 
severity,  but  with  a  bloody  or  dark  liquid  in  the  typhoid  form  of  the  disease. 
This  liquid  sometimes  escapes,  and  concretes  into  thin  and  dark  brown  crusts. 
In  other  cases,  and  probably  from  its  excessive  tension,  the  skin  loses  its 
vitality  to  a  greater  or  less  depth,  and  sloughs  form,  which  may  or  may  not 
involve  the  whole  thickness  of  the  integument.  The  blebs  and  the  sloughs, 
in  a  greater  degree,  are  apt  to  occur  where  the  skin  is  delicate,  as  about  the 
genital  organs,  and  quite  frequently  on  the  eyelids.  Blebs  are  not  very 
uncommon  upon  the  cheeks  and  even  on  the  extremities.  Such  cases  are  not 
to  be  confounded  with  those  of  phlegmonous  erysipelas,  in  which  form  there 
is  less  activity  of  the  disease  in  the  skin  itself  than  underneath  it.  Xor  are 
the  limited  abscesses  which  sometimes  form  beneath  the  skin,  although 
tending  to  augment  the  fever,  to  be  considered  as  constituting  phlegmonous 
erysipelas. 

Meanwhile  the  general  symptoms  become  severe  in  the  same  proportion  as 
the  local  phenomena.  The  temperature  may  reach  or  even  exceed  105°  F., 
by  the  third  day ;  the  pulse  ranges  from  100  to  120,  and  is  only  moderately 
full  and  strong,  while  the  impulse  of  the  heart  and  its  first  sound  are  rela- 
tively feeble ;  the  patient  sutlers  from  headache,  general  distress,  restlessness 
and  sleeplessness,  and  is  apt  to  be  delirious,  especially  at  night,  and  to  be 
somnolent  at  other  times.  Irregular  chills  are  experienced  from  time  to 
time;  the  tongue  is  thickly  coated;  and,  at  the  height  of  the  attack,  nausea, 
vomiting,  and  constipation,  or  diarrhoea,  are  not  uncommon.  At  this  period 
erysipelas  manifests,  even  in  cases  of  average  severity,  a  tendency  to  assume 
the  typhoid  type,  with  a  dry  and  brown  tongue,  tremulous  movements, 
muttering  delirium,  and  imperfect  consciousness,  while  a  small  proportion 
of  albumen  may  be  detected  in  the  urine.  This  tendency  renders  more 
intelligible  the  epidemic  forms  of  the  disease,  in  which  from  the  beginning 
the  same  type  prevails,  clearly  denoting  the  existence  in  the  blood  of  a  poison 
which  primarily  occasions  the  specific  phenomena  of  erysipelas,  and  second- 
arily those  which  are  everywhere  characteristic  of  the  typhoid  state. 

The  temperature  has  more  than  once  been  alluded  to,  but  demands  a  more 
particular  description.  The  rise  to  104°  F.  may  take  place  within  a  few 
hours  after  the  initial  chill.  Most  frequently  this  temperature  continues 
with  but  slight  morning  remissions  as  long  as  the  inflammation  continues  to 
extend,  or  the  evening  exacerbation  may  be  attended  with  a  temperature  of 
105.8°-106.7°  F.,  or,  though  rarely,  107.6°  F.,  while  the  morning  remission 
falls  a  little  below  104°  F.,  and  occasionally  below  102.2°  F.  The  maximum 
temperature  is  not  usually  reached  at  the  end  of  the  fever,  but  one  or  two 
days  earlier.  Defervescence  then  follows,  and  generally,  in  the  course  of  twelve 
hours,  or  in  a  single  night,  the  temperature  falls  to  the  normal  point,  or  very 
nearly  so.  Sometimes,  however,  this  rapid  subsidence  does  not  occur,  espe- 
cially when  the  temperature  has  previously  been  very  high,  but  one  more 
exacerbation  takes  place  in  the  evening,  and  the  normal  degree  is  not  reached 
until  the  following  night.  Not  unusually  the  defervescence  is  less  rapid,  and 
exhibits  something  of  a  remittent  type,  as  in  typhoid  fever.  This  is  most  apt 
to  occur  when  the  inflammation  of  the  skin  subsides  slowly,  or  still  continues, 
but  with  diminished  activity,  to  extend.  Not  infrequently,  after  an  interval 
of  from  one  to  six  days,  and  whether  or  not  it  has  meanwhile  become  normal, 


180  ERYSIPELAS. 

Fig.  8. 

Day  of     Day  of   9S         99  100       101  102       103  104      105 

Month     Disease 

April  24.       1 ^ Morning. 

Evening. 

Morning. 

Evening. 

Morning. 

Evening. 

Morning. 

Evening. 

Morning. 

Evening. 

Morning. 

Evening. 

Morning. 

Evening. 

Morning. 

Evening. 

Morning. 

Evening. 

Morning. 

Evening. 

Morning. 

Evening. 

Morning. 

Evening. 

Chart  showing  variations  of  temperature  in  a  mild  case  of  facial  erysipelas. 


April  25.       2 


April  26.       3 


April  27.      4 


April  28.      5 


April  29.      6 


April  30.       7 


May  1.       8 


May  2.      9 


May  3.     10 


May  4.     11 


May  5.     12 


ft 


SYMPTOMS   OF   ERYSIPELAS.  181 

the  temperature  takes  a  sudden  and  striking  rise,  which  either  accompa- 
nies or  announces  a  new  extension  of  the  erysipelas.  The  relapse,  however, 
does  not  generally  last  as  long  as  the  original  fever,  indeed  for  only  one  or 
two  days  usually,  but  it  may  recur  several  times,  especially  in  the  erratic 
forms  of  erysipelas  ;  nor  does  the  fever  finally  subside  until  the  eruption  per- 
manently disappears.  When  such  relapses  succeed  one  another,  the  fever  de- 
clines with  each  one  more- and  more,  until  with  a  very  slight  eruption  it  may 
become  imperceptible.  In  fatal  cases,  death  generally  occurs  with  a  high 
temperature  (Wunderlieh).  The  exacerbations  and  remissions  now  referred 
to  appear  to  be  in  some  manner  inherent  in  the  disease,  or,  at  least,  their  ex- 
citing causes  elude  observation ;  but  often  the  former  can  be  traced  to  some 
imprudence  in  eating,  some  exposure  to  cold,  or  even  to  undue  mental  excite- 
ment. The  accompanying  diagram  (Fig.  8)  exhibits  the  changes  of  tempera- 
ture in  a  mild  case  of  facial  erysipelas  following  lupus  of  long  standing. 

As  the  fever  subsides,  the  hardness  and  tension  grow  less,  and  the  skin  pits 
more  or  less  under  pressure  ;  the  elevated  ridge  which  abruptly  bounded  the 
inflammation,  subsides,  the  redness  becoming  less  vivid,  and  shading  off  gradu- 
ally into  the  color  of  the  sound  skin.  As  the  tissues  shrink  more  and  more 
towards  their  normal  dimensions,  the  over-stretched  epidermis  becomes  loos- 
ened, and  is  apt  to  be  detached  in  large  flakes,  leaving  the  inflamed  skin  with 
a  new  cuticle,  and  with  more  or  less  of  a  red  color,  which  it  retains  in  some 
degree  for  many  weeks.  When  repeated  renewals  of  erysipelas  occur  in  the 
same  part,  they  may  induce  a  thickening  of  the  skin,  and  in  the  lower  ex- 
tremities are  apt  to  occasion  also  a  permanently  bluish  tint  and  an  cedematous 
condition  of  the  limbs. 

The  tendency  of  erysipelas  in  its  simple  form  to  recur  again  and  again,  and 
not  only  in  attacks  directly  succeeding  one  another,  but  after  an  interval  of 
months  or  years,  presents  one  of  the  strongest  contrasts  between  it  and  the 
eruptive  fevers,  with  which  in  other  respects  its  analogies  are  very  close 
indeed.  It  is  true,  however,  that  the  nature  of  most  of  these  recurrent  cases 
is  open  to  question,  and  that  not  a  few  of  them  seem  to  have  been  instances 
of  erythema  rather  than  of  erysipelas,  or,  as  they  have  been  called  by  Daude, 
eiysipeloids.  Further  remarks  upon  this  point  will  be  found  in  the  section 
on  Diagnosis. 

The  description  which  has  now  been  given  relates  chiefly  to  erysipelas  as 
it  is  observed  in  and  confined  to  the  skin ;  but  when  the  inflammation  ex- 
tends to  subjacent  parts,  the  phenomena  are  different,  and  depend  partly 
upon  the  nature  and  partly  upon  the  extent  of  the  process.  In  general,  its 
extent  is  determined  by  its  nature;  that  is  to  say,  the  more  sthenic  the  in- 
flammation, the  more  apt  it  is  to  be  limited  in  extent ;  the  more  asthenic,  the 
greater  is  the  tendency  of  the  inflammation  to  extend  indefinitely.  In  the 
former  case,  the  system  is  capable  of  establishing  barriers  of  lymph,  which 
circumscribe  the  inflammatory  process  ;  in  the  latter,  this  goes  on  unresisted, 
and  may  spread  far  and  wide  beneath  the  skin.  Yet  the  very  intensity  of 
the  local  inflammation  may  destroy  the  vitality  of  the  skin  in  a  limited  area, 
as  has  already  been  stated  in  regard  to  the  eyelids  and  the  organs  of  genera- 
tion. In  these  cases,  and  generally  at  the  height  of  the  attack,  spots  of  a 
darker  red  appear  on  the  erysipelatous  skin,  which  gradually  grow  livid  and 
black,  and  ultimately  separate  as  eschars.  Or  suppuration  may  occur  be- 
neath the  skin,  in  consequence  of  the  imperfect  supply  of  blood  in  the  part, 
as  not  uncommonly  happens  in  erysipelas  following  wounds  of  the  scalp. 
The  abscesses  referred  to  may  be  conjectured  to  take  their  rise  in  an  inflam- 
mation and  obstruction  of  the  lymphatics  leading  from  the  primary  seat  of 
the  erysipelas ;  they  are  seldom  large,  and  do  not  materially  aftect  the  course 


182  ERYSIPELAS. 

and  issue  of  the  primary  affection.     To  them,  rather  than  to  the  next  form 
to  be  noticed,  should  the  term  "  phlegmonous  erysipelas  "  be  properly  applied. 

Phlegmonous  Erysipelas. — The  affection  usually  described  as  phlegmonous 
erysipelas  is  an  erysipelas  which  originates  most  frequently  in  wounds  that 
involve  both  the  skin  and  the  subcutaneous  connective  tissue,  and  which 
tends  to  diffuse  itself  in  the  latter  and  on  the  former,  without  being  limited 
by  the  formation  of  an  inflammatory  abscess.  It  issues  in  suppuration  or 
gangrene,  or  both  at  once,  and  according  to  its  degree  and  type  is  attended 
with  inflammatory  or  typhoid  phenomena.  The  onset  of  the  attack  gene- 
rally presents  in  a  high  degree  the  premonitory  symptoms  which  have  been 
already  described,  and  the  part  about  to  be  affected  feels  tense  and  heavy. 
When  the  eruption  appears,  the  skin  is  not  of  a  uniform  redness,  but  often 
darker  streaks  are  visible  along  the  lymphatic  vessels,  and  the  corresponding 
glands  are  enlarged  and  tender.  The  skin  is  very  greatly  sAvollen,  hot  and 
hard  to  the  touch,  and  very  painful.  By  degrees  the  tension  and  hardness 
diminish,  and  give  place  to  a  boggy  softness,  with  abatement  of  the  pain. 
Meanwhile,  underneath  the  skin  the  congestion  has  been  followed  by  an  exu- 
dation of  pus  and  a  softening  of  the  connective  tissue,  as  well  as  of  the  cutis. 
Sooner  or  later  the  skin  becomes  eroded,  or  is  opened  by  incision,  and  gives 
issue  to  a  large  quantity  of  thin  and  fetid  pus,  of  a  gray  or  brownish  color, 
and  mixed  with  shreds  of  dead  connective  tissue  that  have  been  aptly  com- 
pared to  "strings  of  wet  tow,"  to  "the  membranes  of  a  young  foetus,"  to 
"  wads  of  wet  chamois  leather,"  etc.  The  destructive  process  is  much  more 
active  in  the  subcutaneous  connective  tissue  than  in  the  skin  itself ;  whence 
it  often  happens  that  the  latter  is  to  a  great  extent  undermined,  and  between 
it  and  the  muscles,  and  among  the  latter,  vast  cavities  are  formed.  A  case  is 
related  in  which  the  whole  integument  of  the  abdomen  thus  became  detached 
from  the  muscles,  without,  however,  destroying  the  vitality  of  any  portion 
of  the  skin  (G.  B.  Wood);  but  more  frequently  the  loosened  skin  mortifies, 
and  vast  ulcers  result,  which  are  difficult  to  heal,  and  often  lead  to  permanent 
contraction  of  the  denuded  parts.  The  general  symptoms  are  apt  to  be 
severe,  and  include  high  fever  and  delirium ;  and  when  suppuration  sets  in, 
there  is  usually  a  chill,  followed  by  increased  fever,  and  often  by  depression, 
prostration,  hectic  sweats,  diarrhoea,  wasting  of  the  tissue,  and,  in  a  word, 
by  all  the  phenomena  of  pya?mia,  including,  in  some  cases,  metastatic  ab- 
scesses. The  examples  of  arthritis  complicating  erysipelas  are  probably  of 
this  nature. 

Dr.  John  Ashhurst,  Jr.,  has  related  1  the  case  of  a  man  who,  without  apparent  cause, 
was  attacked  with  erysipelas  of  the  right  lower  extremity,  accompanied  with  great 
swelling  of  the  knee-joint.  Although  the  general  symptoms  suhsided,  the  joint  re- 
nin ined  enlarged  for  several  weeks,  and  then  gradually  became  smaller.  Some  weeks 
later  the  left  knee  began  to  swell,  and  subsequently  an  opening  formed,  through  which 
pus  was  discharged  to  the  amount  of  a  pint  at  first,  the  discharge,  however,  not  ceasing 
until  the  patient's  death,  which  was  hastened  by  bed-sores.  After  death,  it  was  found 
that  both  knee-joints  were  distended  with  pus,  that  the  cartilages  had  nearly  disap- 
peared,  and  that  the  ends  of  the  thigh-bones  were  eroded. 

It  may  be  objected  that  in  this  case  the  arthritis  was  the  primary,  the  ery- 
sipelas the  secondary,  affection,  and,  indeed,  this  objection  has  been  made  to 
analogous  cases  (Gosselin);  but  the  suppuration  of  the  joints  observed  in  pu- 
erperal  lever,  and  the  close  relation  of  the  latter  disease  to  erysipelas,  renHer 
probable  the  direct  dependence  on  the  latter  of  certain  cases  of  arthritis. 

1  American  Journal  of  the  Medical  Sciences,  July,  1865,  p.  103. 


SYMPTOMS   OF   ERYSIPELAS.  183 

According  to  Gosselin,  an  erysipelatous  inflammation  of  the  joints  may  either 
terminate  by  resolution  without  impairing  the  movements  of  the  limb,  or 
by  suppuration,  and  in  the  latter  case  with  all  the  possible  consequences  of 
such  an  arthritis  from  other  causes. 

(Edematous  Erysipelas. — There  is  a  degree,  or  variety,  of  phlegmonous 
erysipelas  which  has  been  described  as  the  (Edematous;  it  differs  from  the  for- 
mer in  presenting  far  less  active  symptoms,  and  congestive  rather  than  inflam- 
matory. The  color  of  the  skin  is  not  a  bright,  but  a  pale  or  dull,  brownish 
red  ;  the  swelling  is  smooth  and  shining,  and  pits  but  slightly  and  momenta- 
rily on  pressure.  When  incised  or  punctured,  bloody  serum  flows  out.  It 
occupies  the  same  seats  as  idiopathic  erysipelas  in  general,  and  does  not  fre- 
quently accompany  the  traumatic  form. 

Gangrenous  Erysipelas. — Of  gangrenous  erysipelas  it  maybe  remarked,  in 
addition  to  what  has  been  said  above,  that  it  is  oftenest  met  with  among  the 
old  and  feeble,  or  persons  exhausted  by  intemperance  or  disease,  and  in  the 
cachetic  infants  of  scrofulous  or  syphilitic  parents.  It  is  rarely  primary,  but 
usually  arises  in  the  course  of  some  other  affection.  The  color  of  the  skin 
is  a  dusky  red,  which  does  not  disappear  under  pressure  ;  its  heat  is  not 
great,  nor  is  the  pain,  and  the  swelling  is  doughy  and  circumscribed.  Phlyc- 
tenre  form  upon  the  inflamed  skin,  and  discharge  a  thin  and  offensive  serum, 
and  such  parts  are  apt  to  slough,  especially  where  the  skin  is  delicate.  In 
this  Avay  considerable  portions  of  the  scrotum  have  been  lost,  and  cases  are 
recorded  in  which  this  covering  was  entirely  destroyed  and  the  testicles  ex- 
posed, but  which,  nevertheless,  ended  in  recovery.  In  other  cases,  attended 
with  high  fever  and  other  grave  symptoms,  and,  according  to  Gosselin,  be- 
tween the  fifth  and  the  tenth  day,  or  even  later,  there  appear  upon  the  ery- 
sipelatous surface,  and  sometimes  quite  at  its  limit,  one  or  several  dark  spots, 
which  are  moist,  insensible,  and  cold,  and  from  which  the  cuticle  presently 
separates  with  or  without  the  previous  formation  of  phlyctenre.  At  the 
same  time  the  fever  becomes  more  intense,  the  tongue  grows  dry,  the  strength 
fails,  and  gradually  the  patient  sinks,  and  almost  invariably  dies.  Of  these 
different  degrees  or  forms  of  gangrene  affecting  the  skin,  one  appears  to  de- 
pend upon  the  relative  intensity  of  the  inflammation  as  compared  with  the 
resisting  power  of  the  tissue  involved,  while  the  other  seems  to  be  more  es- 
pecially associated  with  that  typhoid  condition  which  everywhere  implies  an 
impaired  vitality  of  the  tissues. 

Howard  Marsh1  describes  an  erysipelatous  inflammation  of  the  scrotum 
and  penis,  which  also  involves  the  surrounding  parts.  It  may  arise  either  as 
a  primary  affection,  and  is  met  with  as  such  chiefly  in  persons  above  middle 
age,  whose  health  is  reduced  in  many  instances  by  advanced  kidney-disease, 
or  may  depend  upon  some  local  condition  in  which  the  original  mischief  was 
deep-seated  abscess  of  the  perineum.  It  was  described  by  Liston  as  "inflam- 
matory oedema,"  and  that  surgeon  declared  that  in  Edinburgh  he  had  had  no 
less  than  six  cases  under  his  care  during  a  very  wet  and  unhealthy  season. 
Mr.  Holmes  has  particularly  pointed  out  that  the  retention  of  urine  which  is 
apt  to  occur  should  be  regarded  as  the  effect,  and  not  the  cause,  of  the  ery- 
sipelatous swelling  of  the  scrotum.  Hence  the  importance  of  determining,  if 
possible,  whether  an  urethral  obstruction  existed  before  the  erysipelas,  and 
also  the  actual  condition  of  the  canal.  If  a  catheter  can  be  passed  readily, 
it  is  evident  that  the  urethra  is  not  strictured,  and  that,  consequently,  there 
is  no  need  of  retaining  in  it  an  instrument,  which  would  only  aggravate  the 

1  Medical  Times  and  Gazette,  September  30,  1865,  p.  363. 


184  ERYSIPELAS. 

renal  and  vesical  disease  which  is  generally  present.  In  regard  to  the  treat- 
ment of  the  swelling  itself,  it  may  be  mentioned,  in  passing,  that  it  has  been 
usual  to  make  free  incisions  into  the  distended  parts. 

In  1791,  Dr.  Percival,  of  Manchester,  England,  described  a  peculiar  affec- 
tion of  the  vulva  in  a  girl  five  years  old ;  and  in  1815,  Mr.  Kinder  Wood 
related  the  history  of  twelve  similar  cases  that  had  occurred  in  his  own  prac- 
tice. Like  erysipelas,  it  usually  had  prodromes  of  two  or  three  days'  dura- 
tion, when  the  difficulty  of  passing  water  drew  attention  to  the  genitals  of 
the  little  patients.  It  was  then  found  that  the  labia  first  became  swollen, 
and  afterwards  inflamed,  blistered  and  ulcerated,  while  the  inflammation  ex- 
tended to  the  thighs.  There  was  no  spontaneous  tendency  to  gangrene.1  The 
reporter  of  the  cases  discusses  the  question  whether  this  disease  was  erysipe- 
latous, and  deeides  in  the  negative ;  but  the  analogies  of  the  affection  with 
erysipelas  render  some  notice  of  it  in  this  place  appropriate. 

Erysipelas  of  the  Face  and  Scalp. — Of  the  local  and  external  varieties 
of  the  disease,  erysipelas  of  the  face,  and  that  of  the  scalp,  demand  a  few 
special  remarks.  The  former  affection  is  by  far  the  most  common  form  of 
the  disease  unconnected  with  surgical  affections.  Preceded  by  the  general 
phenomena  already  described,  the  eruption  usually  makes  its  appearance  upon 
the  bridge  of  the  nose,  in  which  case  it  almost  always  spreads  symmetrically 
to  either  side,  involving  by  turns  the  eyelids,  the  nose,  the  forehead,  the  ears, 
the  cheeks,  and  the  upper  lip,  but  usually  stopping  at  the  junction  of  the 
skin  of  the  forehead  with  the  hairy  scalp.  It  does  not  often  descend  beyond 
the  middle  of  the  neck.  Sometimes  it  begins  on  one  side  of  the  nose,  and, 
indeed,  Mr.  Bird2  affirms  that  its  starting  point  is  most  frequently  the  right 
side  of  the  face.  Not  uncommonly  it  first  affects  one  ear.  Each  of  these 
cases  is  adduced  in  favor  of  the  doctrine  that  the  idiopathic  disease  always 
takes  its  rise  from  a  direct  infection  ;  and  in  these  instances  it  is  held  that 
the  first  impression  of  the  poison  is  upon  the  nasal  and  pharyngeal  mem- 
branes, whence  its  effects  extend  through  the  lachrymal  canal  to  the  face,  or 
through  the  Eustachian  tube  to  the  ear.  As  the  inflammation  spreads  over 
the  face,  the  skin  is  at  first  of  a  scarlet,  and  then  of  a  crimson  or  almost  pur- 
plish color,  and  its  surface  is  tense  and  shining.  The  ears  especially  are  dark 
red.  The  swollen  eyelids  close  the  eyes,  and  obliterate  entirely  the  depres- 
sions of  the  orbits,  while  from  between  them  tears  flow  abundantly;  the  tumid 
nose  and  lips  complete  the  disfigurement,  and  no  trace  of  the  natural  ex- 
pression of  the  face  is  left.  The  deformity  is  exaggerated  when  the  scalp  is 
involved  as  well  as  the  face,  and  no*  only  is  the  pain  singularly  increased  by 
the  unyielding  nature  of  this  integument,  but  cerebral  symptoms  of  excite- 
ment or  stupor  are  often  present.  The  swelling  of  the  ears  renders  hear- 
ing dull,  and  the  obstruction  of  the  nostrils  compels  the  patient  to  breathe 
through  the  mouth.  Very  commonly  phlyctense  form  upon  the  cheeks,  and 
their  escaping  contents  are  apt  to  irritate  the  skin. 

Erichsen3  lays  much  str*ess  on  the  fact  that  the  erysipelas  which  is  so  apt 
to  follow  injuries  of  the  scalp, seldom  arises  unless  the  tendon  of  the  occipito- 
frontalis  muscle  is  divided.  In  that  case,  the  products  of  inflammation 
accumulate  between  the  pericranium  and  the  bone,  causing  a  cellulitis  with 
profuse  suppuration,  the  pus  from  which  undergoes  putrefaction  and  sets  up 
erysipelas.  This  surgeon  denies  that  a  wound  of  the  seal}),  or  the  use  of 
sutures   in  treating   it,  has  any  special  tendency  to  induce  erysipelas,  which 

1  Medico-Chirurgical  Transactions,  vol.  vii.  p.  84. 

2  Ranking'a  Abstract,  No.  xxix.  1859,  p.  85. 

3  Lancet,  January,  1S78,  p.  115. 


SYMPTOMS    OF    ERYSIPELAS.  185 

he  attributes  exclusively  to  the  retention  and  putrefaction  of  the  exudations 
beneath  the  integument.  Hence  he  condemns  all  dressings  which  tend  to 
retain  the  discharges  within  such  wounds.  It  is  of  importance  to  note  that 
in  this  as  in  all  other  forms  of  traumatic  erysipelas,  the  general  precede  the 
local  symptoms.  After  a  chill,  followed  by  fever,  the  wound  becomes  dry 
and  painful,  and  begins  to  be  surrounded  by  an  erysipelatous  blush. 

In  erysipelas  of  the  face,  as  in  other  forms  of  erysipelas,  the  general  symp- 
toms vary  with  the  existing  type,  from  sthenic  to  adynamic,  but  as  this  form 
more  frequently  than  others  affects  persons  previously  in  good  health,  its  type 
is,  on  the  whole,  sthenic,  and  its  issue  favorable.  The  extension  of  the  inflam- 
mation to  the  scalp  is  doubly  inauspicious,  for  it  not  only  denotes  an  inability 
to  prevent  the  spread  of  the  disease,  but  directly  aggravates  it  by  giving 
rise  to  derangements  of  the  brain  functions.  Although  delirium  is  apt  to 
occur  in  erysipelas  of  the  face,  it  is  much  more  marked  in  that  of  the 
scalp,  when  it  is  usually  low  and  muttering,  though  occasionally  maniacal. 
In  all  forms  of  erysipelas,  however,  provided  that  the  temperature  is  high, 
there  is  more  or  less  tendency  to  delirium.  At  night  it  is  of  common  occur- 
rence, even  when  the  eruption  is  confined  to  the  face.  It  does  not  arise  from 
inflammation  of  the  brain  or  its  meninges, for  after  death,  in  cases  presenting 
this  symptom  even  in  an  aggravated  degree,  no  inflammatory  exudation  has 
ever  been  found  within  the  cranium,  and  not  even  venous  congestion  uni- 
formly. The  delirium  and  coma  preceding  the  fatal  issue  of  the  disease 
must  therefore  be  attributed  either  to  congestion  of  the  brain  or  to  an  altered 
condition  of  the  blood,  or  to  both  of  these  causes  together.  Many  years  ago 
(1860),  Todd  combated  the  prevalent  idea  that  the  cerebral  symptoms  of 
erysipelas  were  produced  by  a  lesion  of  the  brain,  and  explained  them  by  the 
circulation  of  noxious  blood  through  that  organ.  On  the  whole,  we  may 
fairly  conclude  that  congestion  has  a  share  in  producing  the  brain  symptoms, 
because  they  are  more  frequent  in  erysipelas  of  the  scalp  than  in  that  of  any 
other  part ;  but  that  the  blood  lesion  shares  in  their  production  is  denoted  by 
the  occurrence  of  coma  in  the  puerperal  and  other  forms  of  epidemic  erysipelas, 
in  connection  with  gangrene  and  evidences  of  blood-poisoning. 

Many  writers  have  attached  importance  to  the  gastric  derangements  in 
this  form  of  erysipelas,  and  have  described  vomiting,  and  especially  bilious 
vomiting,  as  quite  characteristic  of  it.  The  sjmiptom  does  indeed  often 
occur,  but  perhaps  is  quite  as  often  wanting.  There  is  less  reason  for  sup- 
posing that  it  is  occasioned  by  any  special  disorder  of  the  stomach  or  liver, 
than  for  regarding  it  as  a  sympathetic  phenomenon  due  either  to  the  altered 
quantity  or  to  the  quality  of  the  blood  circulating  in  the  brain. 

The  duration  of  erysipelas  of  the  face,  especially  when  idiopathic,  may  be 
stated  at  from  one  to  two  weeks ;  but  this  may  be  greatly  exceeded  when  the 
disease  involves  the  scalp,  or  becomes  phlegmonous.  This  form  of  the  disease 
is  perhaps  less  liable  than  others  to  relapses.  Besides  the  sequelas  common 
to  all  the  forms,  there  is  one  that  is  indeed  rare  and  seems  peculiar  to  erysip- 
elas of  the  face.  It  is  blindness,  due  to  an  atrophic  degeneration  of  the  optic 
papilla,  which  sometimes  affects  only  one  eye,  and  sometimes  both  eyes. 
The  impairment  of  sight  when  it  occurs  only  in  one  eye,  begins  towards  the 
close  of  the  attack,  or  when  the  swelling  of  the  eyelids  has  subsided  suffi- 
ciently to  permit  them  to  be  raised.  When  both  eyes  have  been  involved, 
the  impairment  of  sight  appears^  not  to  have  been  noticed  before  the  com- 
plete subsidence  of  the  erysipelas,  and,  after  varying  in  degree,  to  have  left 
a  permanent  defect  of  vision,  sometimes,  however,  in  regard  only  to  certain 
colors.1 

1  Parinaud,  Archives  Generales  de  M^decine,  Juin,  1S79,  p.  641 . 


186  ERYSIPELAS. 

A  quite  unusual  seat  of  the  eruption  presented  itself  in  a  case  of  Steiner's.1  In  a 
child  two  years  of  age,  without  known  cause,  the  disease  attacked  simultaneously  both 
thighs,  and  then  extended  to  the  feet.  •  After  it  declined  there  a  relapse  occurred,  the 
eruption  appeared  upon  the  trunk,  and  the  child  died. 

Bilious  Erysipelas. — The  bilious  phenomena  above  alluded  to  have  such 
a  predominance  in  certain  instances,  that  to  cases  presenting  them  has  been 
applied  the  title  bilious  erysipelas.  The  cases  now  alluded  to  occur  in 
localities  and  at  seasons  in  which  a  malarial  influence  prevails,  and  they  are 
marked  by  bilious  eructation  and  vomiting,  bitterness  of  the  mouth,  a. 
yellow  tongue,  epigastric  uneasiness  and  tenderness,  great  thirst,  sometimes 
constipation,  or,  again,  bilious  diarrhoea,  scanty  and  yellow  urine,  and  yellow- 
ness of  the  skin  or  conjunctivae. 

Metastatic  Erysipelas. — Erysipelas  is  said  to  be  metastatic,  when  it  dis- 
appears abruptly  from  one  place  to  reappear  as  suddenly  in  some  other 
part.  Thus  it  may  pass  from  the  face  to  the  external  genital  organs,  from 
the  ear  to  the  limbs,  from  the  skin  to  some  internal  part,  etc.  This  trans- 
lation is  sometimes  produced  by  cold  air,  or  by  the  application  of  cold  or 
astringent  lotions.  Such  phenomena  illustrate  the  doctrine  that  erysipelas 
is  not  a  local  inflammation,  but  a  disease  involving  the  whole  system,  just  as 
analogous  metastases  show  a  similar  nature  in  gout  and  rheumatism.  The 
change  of  seat,  moreover,  does  not  always  take  place  abruptly;  an  internal 
organ  may  be  attacked  after  the  complete  resolution  of  the  original  inflam- 
mation, presenting,  in  fact,  the  characters  of  a  relapse  in  which  the  seat  of 
the  secondary  is  quite  different  in  its  character  from  that  of  the  primary 
affection.     For  example: — 

A  young  and  healthy  man  experienced  an  attack  of  erysipelas  of  the  face  and  scalp, 
which  ran  the  usual,  and  a  favorable  course,  even  to  desquamation.  After  six  days  of 
apparent  convalescence,  the  patient  was  attacked  with  pain  in  the  right  side  of  the 
chest,  cough,  fever,  sore  throat,  redness  of  the  fauces,  and  crepitant  rales  at  the  base 
of  the  right  lung.  Death  occurred  in  four  days,  when  the  pharynx  was  found  of  a 
bright  red  color  which  ceased  abruptly  at  the  oesophagus,  but  extended  into  the  larynx, 
trachea,  and  right  bronchus,  even  to  its  smallest  subdivisions,  though  it  did  not  affect 
the  left.  The  alveoli  of  the  right  lung  were  distended  with  leucocytes,  but  there  were 
no  bronchial  casts,  nor  did  any  hepatization  exist.  The  nature  of  the  exudation  was 
characteristic  of  erysipelatous,  but  not  of  "  croupous"  or  fibrinous  inflammation.  The 
disease,  in  this  case,  appears  to  have  made  two  separate  and  independent  attacks  ;  but 
whether  the  poison  that  occasioned  the  second  was  the  same  that  produced  the  first, 
and  afterwards  remained  quiescent  in  the  system,  or  whether  the  relapse  was  due  to  a 
fresh  infection,  may  remain  in  doubt,  the  former  view,  however,  seeming  to  be  the 
more  probable. 

Erysipelas  of  New-born  Infants. — Erysipelas  in  new-born  children,  at  least 
in  its  epidemic  form,  is,  as  was  long  ago  observed,  almost  entirely  confined 
to  lying-in  hospitals.  It  was  doubted  by  Underwood  whether  it  ever  affected 
those  who  were  more  than  a  month  old,  but,  unless  those  cases  alone  are 
regarded  which  originate  in  section  of  the  umbilical  cord,  this  opinion  is  too 
exclusive.  The  disease  sometimes  prevails  among  children  of  one  or  two 
years,  confined  iii  hospitals.  On  the  other  hand,  it  is  known  to  have  occurred 
during  infra-uterine  life,  as  in  Bromfield's2  case,  in  which  the  child  was  born 
with  erysipelas  of  the  face  and  legs,  and  in  which,  although  sloughs  existed 
on  the  latter  at  birth,  recovery  followed.     In  nearly  all  cases  of  this  form, 

'  Prager  Vierteljahrsohrift,  IM.  lxxxix.  Anal.  S.  67. 

2  Medical  Communications,  vol.  ii.  p.  22. 


SYMPTOMS   OF   ERYSIPELAS.  187 

the  erysipelas  is  distinctly  traumatic,  and  takes  its  starting-point  from  the 
divided  umbilical  cord  ;  but  it  as  distinctly  coincides  with  epidemics  of 
puerperal  fever,  and  must  be  attributed  to  the  same  essential  cause  as  that 
affection.  Trousseau,  at  an  early  period  of  his  career,  pointed  out  this  rela- 
tionship between  the  two  diseases,  and  in  1855,  Lorain  stated  that  under  the 
same  conditions  infants  also  perished  with  peritonitis,  abscesses,  septicemia, 
and  gangrene  of  the  limbs,  and  that  in  the  greater  number  of  sueh  eases  the 
mothers  had  died  of  puerperal  fever.  Isunneley  followed  Underwood  in 
noting  the  extremely  sudden  onset  and  rapid  development  of  the  inflamma- 
tion, and  Trousseau  insisted  upon  the  same  point,  and  also  upon  the  almost 
•inevitable  fatality  of  the  disease  within  the  first  two  or  three  weeks  after 
birth.1  It  generally  begins  to  show  itself  at  the  pubes,  extending  rapidly 
upward  on  the  abdomen,  and  downward  upon  the  thighs  and  genitals,  which 
grow  exceedingly  red,  swollen,  hard,  and  cedematous,  and  then  purplish  ; 
phlyctenas  form,  and  the  skin  is  attacked  with  gangrene.  The  infant  at 
the  same  time  falls  into  a  state  of  prostration,  yet  has  scarcely  any  fever  at 
first;  but  as  the  inflammation  spreads  and  grows  more  intense,  fever  comes 
on  with  pain,  and  there  is  great  restlessness,  sleeplessness,  and  debility,  with 
vomiting  and  diarrhoea,  which  rapidly  exhaust  the  strength  and  bring  on  a 
fatal  issue  from  the  fifth  to  the  seventh  day.  This  termination  is  sometimes 
due  to  gangrene  of  the  erysipelatous  parts,  and  sometimes  to  the  formation 
of  abscesses,  although,  according  to  Trousseau,  the  latter  occurrence  is,  on 
the  whole,  a  favorable  sign. 

Erysipelatous  Peritonitis. — This  form  of  erysipelas  was  first  described 
in  1828,  by  Abercrombie,2  who  alludes  to  its  symptoms  as  being  sometimes 
slight  and  insidious,  though  sometimes  very  severe,  but  as  chiefly  distin- 
guished by  the  rapidity  with  which  they  run  their  course,  and  by  a  re- 
markable sinking  of  the  vital  powers,  which  occurs  from  an  early  period, 
and  often  prevents  the  adoption  of  any  active  treatment.  In  one  of  the 
cases  related  by  this  author,  an  erysipelas  of  the  leg  abruptly  subsided, 
the  patient  was  seized  with  symptoms  of  peritonitis,  and  died  in  a  little 
more  than  twenty-four  hours  from  the  time  of  the  attack.  In  another  case, 
the  primary  attack  was  an  erysipelas  of  the  throat,  but  during  convalescence 
the  patient  was  suddenly  seized  with  violent  pains  in  the  abdomen,  followed 
by  collapse  and  death  in  about  forty-eight  hours  from  the  commencement. 
In  the  Merchants'  Hospital  (a  charitable  institution  for  the  education  of 
girls),  and  while  an  epidemic  of  erysipelas  of  the  throat  prevailed  in  Edin- 
burgh, a  number  of  the  inmates  were  attacked  with  the  disease  in  a  similar 
form ;  but,  after  a  week,  one  of  the  girls  who  seemed  to  be  entering  on  con- 
valescence, was  suddenly  seized  with  symptoms  of  peritonitis,  including 
vomiting,  diarrhoea,  pain,  and  collapse,  of  which  in  a  few  hours  she  died.  A 
second  fatal  case  occurred  with  nearly  identical  symptoms ;  and  in  both  of 
them  inspection  after  death  revealed  the  lesions  of  peritonitis,  including  an 
exudation  which  was  puriform  rather  than  fibrinous.  Abercrombie  makes 
the^ following  commentary:  "This  affection  differs  from  the  usual  forms  of 
peritonitis;  and,  without  speculating  further  upon  the  nature  of  it,  we  may 
add  that  its  alliance  to  erysipelas  appears  to  be  an  obvious  and  remarkable 
character  of  the  disease." 

1  Lectures  on  Clinical  Medicine,  New  Sydenham  Society's  edition,  vol.  ii.  p.  271. 

2  Pathological  and  Practical  Researches,  etc.,  p.  181.  ■ 


188  ERYSIPELAS. 


Diagnosis  of  Erysipelas. 

The  direct  or  positive  diagnosis  of  erysipelas  may  frequently  be  made  before 
the  actual  appearance  of  the  eruption  upon  the  skin  or  adjacent  mucous 
membrane.  It  rests  primarily  upon  the  swelling,  redness,  and  tenderness  of 
the  lymphatic  glands  connected  with  the  part  about  to  be  attacked.  Those 
of  the  neck  usually  present  such  appearances  in  erysipelas  of  the  face  or 
thmat ;  those  of  the  axilla  or  the  groin,  in  erysipelas  of  the  upper  or  lower 
extremities.  "When  the  inflammation  itself  appears,  it  may  be  recognized  by 
the  uniform  pink  or  rose  color  of  the  skin,  which  in  the  throat  assumes  a 
dusk}'  hue ;  by  the  rapid  swelling  of  the  integument,  accompanied  w^ith  a 
burning  heat  of  the  part;  and  especially  by  the  abrupt  ridge  that  divides  the 
inflamed  from  the  unaffected  skin,  the  rapid  encroachment  upon  the  latter 
of  the  inflammation,  and  the  equally  rapid  rise  of  the  temperature.  These 
signs  distinguish  erysipelas  from  lymphangeitis  or  avgeioleucitis,  in  which  the 
swelling  is  less,  and  the  redness,  instead  of  being  uniform,  follows  the  trunks 
of  the  lymphatics,  and  is  therefore  streaked,  and  also  presents  limited  and 
indurated  swellings,  and  is  not  abruptly  bounded  by  the  sound  skin.  It  does 
not  follow,  however,  that  the  two  affections  may  not  coexist  in  the  same  case. 
Erythema,  such  as  is  at  all  likely  to  be  confounded  with  erysipelas,  is  a  much 
more  superficial  inflammation  of  the  skin,  and  its  edges  are  not  abrupt  and 
elevated  as  in  the  other  disease.  "When  it  occurs,  as  it  often  does,  upon 
tt'deinatous  or  dropsical  parts,  this  sign  is  distinctive,  especially  as  the  affec- 
tion is  not  attended  with  the  febrile  movement  which  accompanies  erysipelas. 
When  it  is  traumatic,  it  is  more  apt  to  arise  from  abrasions,  from  friction, 
etc.,  than  from  a  division  of  the  tissues.  Yet  it  is  not  uncommon  around 
certain  more  deeply  seated  lesions,  such  as  old  ulcers,  especially  of  the  legs. 

Volkmann  has  directed  attention  to  the  difficulty  of  distinguishing  from 
phlegmonous  erysipelas,  a  diffused  inflammation  of  the  connective  tissue  which 
results  from  severe  injuries,  and  which  presents  an  irregular  and  often  dull  red- 
ness and  an  cedematous  swelling  of  the  skin.  lie  notes  as  distinctive  marks  of 
this  affection,  a  slow  development  of  fever,  with  a  relatively  rapid  appearance 
of  bluish-red  or  dusky,  venous  congestion,  a  doughy  state  of  the  swelling,  and 
a  peculiar  sanious  or  gangrenous  aspect  of  the  original  wound,  while  the  gene- 
ral condition  of  the  patient  does  not  present  any  grave  disorder.  It  is  to 
these  contrasts,  in  a  particular  case,  that  Erichsen  probably  alludes  when  he 
speaks  of  the  difficulty  of  distinguishing  between  abscess  of  the  scalp  and 
erysipelas.1  But  while  in  both  there  may  be  fluctuation,  it  is  in  abscess 
always  limited  by  the  attachments  of  the  occipito-frontalis  muscle  to  the 
occipital  ridge  and  the  zygoma,  while  in  front  the  pus  will  be  apt  to  gravitate 
towards  the  eyes,  and  form  a  puffy  swelling  of  the  eyelids.  But  in  diffused 
erysipelas  of  the  seal}),  the  ears  are  always  involved,  and  become  red,  swollen, 
and  covered  with  blebs. 

Prognosis  or  Erysipelas. 

The  prognosis  of  erysipelas  varies,  according  to  the  character  of  the  attack, 
from  almost  absolute  safety  to  as  absolute  fatality.  The  former  estimate 
rd'.is  to  the  idiopathic,  sporadic  disease,  the  latter  to  the  epidemic  puerperal 
form.  Between  these  two  extremes  lie  the  large  number  of  cases  of  surgical 
erysipelas  in  which  the  mortality  fluctuates  indefinitely,  and  chiefly  with  the 
dominant  type  of  the  disease, 

1  Lancet,  January,  1878,  p.  115. 


PROGNOSIS   OF   ERYSIPELAS.  189 

First,  in  regard  to  medical  erysipelas  occurring  primarily  and  confined  to 
the  skin,  the  prognosis  is  generally  favorable.  One  of  the  greatest  of  French 
clinicians,  Chomel,  declared  that  he  had  never  seen  a  fatal  case  of  primary 
erysipelas  of  the  face  ;  and  Trousseau,  whose  immense  experience  gives  his 
statement  great  weight  in  such  a  matter,  stated  that  of  the  large  number  of 
cases  of  this  affection  which  he  had  seen,  not  more  than  three  had  proved 
fatal.  During  a  period  of  four  years  he  met  with  but  one  death  in  fifty- 
seven  hospital  cases,  and  in  it  the  hairy  scalp  was  involved.  Indeed,  he  was 
disposed  to  regard  this  most  ordinary  form  of  the  disease  as  benignant  in  its 
character,  and  even  less  fatal  than  bronchitis ;  and  he  charged  that  where 
recoveries  had  taken  place  after  the  use  of  bleeding  or  purging,  or  the  em- 
ployment of  emetics,  blisters,  or  cauterizations,  they  had  occurred  not  in  con- 
sequence of  the  treatment,  but  in  spite  of  it.1  Our  own  experience  coincides 
perfectly  with  this,  for  we  have  never  yet  met  with  a  fatal  case  of  primary, 
idiopathic  erysipelas  of  the  face  in  hospital  or  in  private  practice,  where  the 
disease  was  submitted  to  a  palliative  or  a  supporting  treatment.  But  Ave 
have  seen  it  fatal  under  the  use  of  evacuant,  sedative,  and  so-called  alterative 
measures. 

If,  however,  we  take  all  the  accessible  reports  of  the  mortality  from  idio- 
pathic erysipelas  of  the  skin,  which  have  emanated  from  hospitals,  especially 
in  Europe,  a  different  result  is  obtained.  For  instance,  in  the  Parisian  hos- 
pitals, in  1862,  there  occurred  759  cases  of  various  forms  of  non-traumatic 
erysipelas.  Of  these,  nearly  17  per  cent,  terminated  fatally,  while  in  the  fol- 
lowing year  the  mortality  was  only  8.5  per  cent.  In  still  stronger  contrast 
with  the  usual  mortality  of  the  disease,  as  it  is  seen  in  this  country,  the  fur- 
ther statement  may  be  made  that  during  the  two  periods  just  mentioned,  in 
Paris,  the  mortality  of  surgical  erysipelas  was,  for  the  former,  nearly  78  per 
cent.,  and  for  the  latter  nearly  77  per  cent.  In  this  country  no  such  lament- 
able results  have  ever  been  observed,  not  even  during  our  civil  war. 

It  has  been  stated  elsewhere  that  erysipelas  occurring  within  the  first 
month  of  life,  is  nearly  always  fatal  ;  but  once  this  period  is  passed,  the  issue 
of  the  disease  depends  upon  the  same  general  conditions  as  in  the  case  of 
older  persons,  and  especially  upon  the  original  vigor  of  the  patient,  and  the 
appropriateness  of  the  hygienic  and  medicinal  treatment. 

It  is  proper  to  state  once  more,  what  has  been  already  mentioned,  that  the 
decline  of  an  attack  of  erysipelas  of  the  skin  is  always  to  be  expected  when  the 
inflamed  area  shades  off  gradually  into  the  sound  skin ;  while,  as  long  as  it 
is  abrupt,  a  further  extension  may  be  looked  for.  But  even  after  the  com- 
plete subsidence  of  the  inflammation,  a  relapse  may  take  place,  and  in  some 
persons  the  attack  recurs  repeatedly,  even  after  long  intervals.  It  appears 
that  this  tendency  has  been  exaggerated  by  confounding  together  erythema 
and  erysipelas.  However  this  may  be,  the  liability  of  erysipelas  to  relapse 
is  most  apt  to  be  exhibited  in  hospitals  and  other  places  where  a  number  of 
cases  of  the  disease  have  been  brought  together.  In  his  account  of  one  hos- 
pital epidemic,  Miller  states2  that  out  of  twenty  cases,  six  suffered  relapse, 
four  of  them  once,  one  of  them  twice,  and  one  five  times ;  and  that  on  almost 
every  occasion  the  fresh  attack  could  be  traced  to  infection  by  a  newly  ad- 
mitted patient.  According  to  Gosselin,3  the  secondary  eruption  usually  oc- 
cupies the  same  seat  as  the  primary,  extends  more  rapidly  than  it,  runs  its 
course  in  a  shorter  time,  and  always  ends  in  cure. 

Erysipelas  commencing  distinctly  in  the  fauces,  or  invading  them  by  exten- 

•  Clinical  Medicine,  vol.  ii.  p.  263. 

2  Edinburgh  Medical  Journal,  vol.  xxv.  p.  1095. 

3  Dictionnaire  de  Medecine  et  de  Chirurgie  Pratiques,  t.  xiv.  p.  25. 


190  ERYSIPELAS. 

sion  from  the  face,  or  extending  to  the  air  passages  or  to  the  brain,  from  the 
throat  or  from  the  scalp,  always  involves  danger.  Phlegmonous  and  gangren- 
ous erysipelas  are  dangerous  in  proportion  to  their  extent,  and  to  their  tend- 
ency to  spread  without  limit.  Suppuration  in  the  form  of  ahscesses  involves 
no  special  danger.  As  a  common  exciting  cause  of  traumatic  erysipelas  is 
alcoholic  intemperance,  so  does  this  habit  also  render  the  issue  of  the  disease 
less  favorable  ;  it  tends  to  favor  the  extension  of  the  inflammation,  and  to 
increase  the  risk  of  suppuration  and  gangrene,  as  well  as  to  bring  about  that 
typhoid  state  of  the  system  which  constitutes  one  of  the  greatest  dangers  of 
erysipelas.  Erratic  erysipelas  is  not  severe  in  itself  at  any  one  time,  but  by  its 
recurrence  and  its  duration  for  many  weeks,  or  even  months,  may  gradually 
exhaust  the  patient's  strength. 

In  the  epidemic  form  of  erysipelas,  and  in  those  local  outbreaks  of  the  dis- 
ease wThich  sometimes  assume  an  equally  low  type,  the  danger  of  death  is 
great  in  proportion  to  the  degree  in  which  the  typhoid  state  is  exhibited,  due 
regard  being  had  to  the  original  soundness  and  vigor  of  the  patient.  When 
the  disease  is  confined  to  the  throat,  or  when  it  also  attacks  the  skin,  the  dis- 
ease is  seldom  fatal,  unless  it  acquire  a  phlegmonous  character  in  the  former 
situation.  This  is  especially  true  of  cases  in  private  practice.  The  most 
fatal  form  of  erysipelas  is  that  which  attacks  internal  organs,  and  especially 
the  lungs  and  peritoneum.  In  both  cases  the  hope  of  recovery  is  very  small ; 
but  in  puerperal  peritonitis  of  erysipelatous  origin  the  mortality  is  almost  ab- 
solute, and  the  rapidity  of  the  fatal  course  is  often  as  appalling  as  its  issue  is 
inevitable. 

In  general  terms,  the  conditions  that  increase  the  danger  of  erysipelas  are 
such  as  involve  debility,  including  infancy,  old  age,  and  complication  by  pre- 
viously existing  or  concomitant  diseases,  such  as  phthisis,  Bright's  disease, 
diphtheria,  or  the  eruptive  and  typhous  fevers.  Moreover,  death  has  occurred 
by  hemorrhage  from  the  bowels  in  a  case  which  was  otherwise  benign,  and 
in  which  no  lesion  could  be  found  to  account  for  the  accident.1  Finally, 
blindness  has  been  known  to  result  from  erysipelas  of  the  face,  as  in  the  case 
of  Despagnet.2 

,  Prophylaxis  of  Erysipelas. 

The  measures  which  it  is  advisable  to  adopt  for  the  prevention  of  erysipe- 
las may  readily  be  inferred  from  the  description  of  the  causes  heretofore  given. 
They  may  all  be  included  in  the  following  rules : — 

I.  The  utmost  purity  of  the  air  should  be  preserved  in  all  apartments 
habitually  used  by  day,  or  for  sleeping,  and  especially  in  hospital  wards  and 
other  places  occupied  by  the  sick. 

II.  All  patients  suffering  from  erysipelas  should  be  isolated,  and  nothing 
that  has  been  used  by  or  for  them,  and,  least  of  all,  surgical  instruments,  should 
be  em  ployed  for  non-crysipclatous  patients.  On  the  same  principle,  in  climates 
and  seasons  which  make  it  possible  to  treat  the  wounded  in  tents  or  in  tem- 
porary  wooden  hospitals,  such  as  were  used  during  our  civil  war,  the  danger 
of  erysipelas  is  reduced  to  a  minimum  by  doing  so. 

III.  On  no  account  should  a  puerperal  patient  be  confined  in  a  house  in- 
fected  with  erysipelas,  nor  be  attended  by  any  physician  who  has  recently 
had  charge  of  an  erysipelatous  case. 

IV.  A  surgical  ward  should  never  be  in  close  proximity  to  a  lying-in  wTard, 

»  Archiv  der  Heilkunde,  Bd.  xi.  S.  398. 
2  Kooiioil  d' Ophthalmologic,  Paris,  1880. 


TREATMENT    OF    ERYSIPELAS.  191 

nor  even  in  the  same  building,  and  the  attendants  in  one  should  hold  no  com- 
munication with  those  of  the  other. 

V.  During  general  or  local  epidemics  of  erysipelas,  all  cutting  operations 
should  be,  if  possible,  avoided,  it  being  remembered  that  the  danger  of  the 
erysipelatous  infection  of  wounds  is  in  direct  proportion  to  their  extent. 

VI.  For  the  reason  just  mentioned,  it  is  held  by  some  surgeons  that  subcu- 
taneous incisions  should,  under  such  circumstances,  be  preferred,  and  that  the 
surface  of  recent  wounds  should  be  protected  by  a  nitrate  of  silver  film. 


Treatment  of  Erysipelas. 

The  most  ancient  treatment  of  erysipelas,  as  described  by  Hippocrates, 
consisted  in  the  application  of  cold  water,  provided  that  no  ulceration  of  the 
skin  existed.1  According  to  Paul  of  ^"Egina,2  if  the  patient's  strength  per- 
mit, blood-letting  and  cholagogue  medicines  should  be  employed,  with  the 
topical  use  of  ointments  overlaid  with  cooling  lotions.  This  writer  also  re- 
commends emollient  poultices  made  from  various  mucilaginous  plants,  with 
the  addition  of  anodynes,  and,  at  a  later  stage  of  the  disease,  cooling  or  astrin- 
gent applications,  some  of  the  former  containing  vinegar,  and  some  of  the 
latter  saturnine  solutions,  potter's  clay,  and  various  astringents,  including 
copperas  and  alum.  He  also  refers  to  the  necessity  of  incising  the  skin  when 
mortification  threatens  (a  recommendation  made  also  by  Galen  and  his  suc- 
cessors), and  speaks  of  the  virtues  of  hot  or  salt  water  in  chronic  states  of 
the  affection.  It  is  worthy  of  remark  that  he  and  nearly  all  medical  authors 
from  the  most  ancient  times,  dissuade  from  depletion  in  this  disease,  although 
some  Arabian  authors  are  exceptions  to  this  statement.  Another  point  upon 
which  there  is  a  general  agreement,  is  the  administration  of  certain  purga- 
tives supposed  to  be  cholagogue.  Whether  this  practice  rested  on  the  fact , 
that  epidemic  erysipelas  was  apt  to  be  attended  with  jaundice,  or  upon  the 
authority  of  Galen,  who  enjoined  it  upon  grounds  that  now  seem  quite  futile, 
it  is  unnecessary  to  inquire.  Beyond  a  doubt,  the  practice  itself  is  good  at 
the  commencement  of  an  attack,  especially  when  it  is  associated  with  the 
use  of  emetics,  which  the  ancients  do  not  appear  to  have  employed  in  this 
disease.  Celsus3  gives  the  same  qualified  advice  respecting  venesection,  and 
directs  the  use  of  cooling  and  astringent  applications,  especially  ceruse  and 
solanum  (dulcamara  ?),  or  chalk.  He  adds  that  whatever  topical  remedies 
are  used,  should  be  applied  cold,  and  kept  covered  to  prevent  their  getting 
dry.  But  he  is  by  no  means  prejudiced  in  favor  of  this  refrigerant  method,  for 
he  enjoins,  if  its  effects  should  not  be  favorable,  that  stimulants  and  astringents 
infused  in  wine  should  be  substituted  for  it,  and,  if  the  part  should  still  re- 
main indurated,  that  anodyne  ointments  and  cataplasms  should  be  applied. 

The  history  of  erysipelas  illustrates  the  general  truth  in  therapeutics,  that 
modes  of  treatment,  and  especially  of  acute  febrile  affections,  should  be  de- 
termined by  their  type,  rather  than  by  their  essential  nature.  In  a  large 
number  of  cases,  it  is  so  far  local  and  superficial  that  its  treatment  may  be 
confided  to  protectives  and  palliatives ;  in  many  more,  an  active  antiphlo- 
gistic method  will  be  tolerated,  even  if  not  really  indicated  ;  but  in  a  still 
more  numerous  class,  and  especially  during  epidemics,  whether  nosocomial' 
or  more  widely  spread,  and  whether  idiopathic  and  primary  or  puerperal  or 
traumatic,  a  general  treatment  at  once  stimulant,  supporting,  and  tonic,  is  the 
only  one  from  which  favorable  results  can  be  expected.     In  this  disease,  as  in 

1  Works,  Sydenham  Society's  edition,  vol.  ii.  p.  741. 

8  Sydenham  Society's  edition,  vol.  ii.  p.  66.  3  Lib.  v.  cap.  xsvi.  sect.  33. 


192  ERYSIPELAS. 

all  that  tend  to  assume  a  typhoid  type,  the  sagacity  of  a  physician  is  dis- 
played less  in  the  general  plan  of  treatment  he  pursues,  than  in  the  modifica- 
tions by  which  he  adapts  it  to  the  peculiarities  of  individual  cases.  He  will 
keep  constantly  in  mind  that  he  is  not  treating  an  abstract  disease  with  ab- 
stract remedies,  but  human  beings,  whose  health  or  life  may  depend  upon  his 
use  of  agents  that  may  be  mischievous  or  salutary,  according  to  the  manner 
in  which  they  are  employed. 

In  no  disease  more  than  in  erysipelas,  have  greater  errors  been  committed 
by  overlooking  its  natural  history.  Internal  medicines,  the  most  diverse  in 
their  nature  and  the  most  opposite  in  their  effects,  have,  at  different  times, 
or  by  different  physicians,  been  equally  vaunted  as  cures  for  this  disease. 
At  one  time  depletion,  at  another  stimulants,  now  sedatives,  and  now  tonics, 
have  been  in  vogue,  while  external  applications,  as  opposite  to  one  another 
as  oil  or  mucilage,  on  the  one  hand,  and  mercury,  iron,  and  nitrate  of  silver, 
on  the  other,  have  alike  enjoyed  a  temporary  or  local  favor.  One  acquainted 
with  the  history  of  therapeutics  must  regard  the  claims  constantly  and  con- 
fidently put  forward  in  favor  of  successive  remedies,  as  exhibiting  a  very  in- 
sufficient acquaintance  either  with  this  particular  disease  or  with  the  laws 
which  should  govern  the  search  after  truth.  The  instructed  pathologist  and 
therapeutist  knows  that  the  majority  of  the  cases  of  acute  disease  tend,  under 
favorable  circumstances,  to  recovery,  and  therefore  require  only  a  palliative 
and  expectant  treatment ;  and  he  also  knows  that  under  exceptional  circum- 
stances, as  during  certain  epidemics,  death  is  the  necessary  end  of  most  of 
the  cases.  Only  on  the  middle  ground  between  these  two  extremes  is  it  that 
the  physician  is  of  much  avail  to  determine  the  issue ;  at  either  extreme  his 
influence  is  limited  to  smoothing  the  way  to  death,  or  rendering  easier  and 
more  pleasant  a  return  to  health.  To  abstain  from  interference  when  it  is 
needless,  is  as  high  a  duty  as  to  interfere  when  it  is  necessary,  and  rightly  to 
judge  how  far  the  intervention  should  proceed.  It  may  be  laid  down  as  the 
law  of  non-epidemic  erysipelas  in  general,  when  it  occurs  in  a  previously 
healthy  person,  and  is  not  complicated  with  septicaemia  in  traumatic  cases, 
that  it  tends  spontaneously  to  recovery ;  and  that  in  simple,  or  so-called  idio- 
pathic cases,  such  a  result  may  be  looked  for  within  a  week.  Even  if  it  be 
possible  to  shorten  this  duration  by  the  use  of  certain  medicines,  the  gain  is 
a  gain  of  time  rather  than  of  life  over  death. 

Such  is  the  verdict  of  experience,  and  no  ingenuity  of  scientific  pleading 
can  set  it  aside.  "  When,"  said  Trousseau,  "  a  patient  suffering  from  erysip- 
elas is  placed  under  my  care,  my  rule  is  to  abstain  from  every  kind  of  treat- 
ment," and  he  adds  that  such  had  been  his  plan  for  twenty-eight  years,  and 
that,  thanks  to  it,  he  could  not  remember  losing  more  than  three  persons 
from  erysipelas  during  that  period.  He  insisted  on  the  importance  of  keeping 
patients  in  bed,  both  "in  the  acute  stage  and  during  convalescence,  to  prevent 
their  catching  cold  and  suffering  relapse;  he  prescribed  acidulated  drinks, 
laxatives  if  the  bowels  were  confined,  and  purgatives  if  the  vomiting  were 
violent.  But  Ik-  insisted  also  on  the  necessity  of  giving  food,  in  spite  of  fever 
and  even  of  delirium,  and  of  avoiding  whatever  would  debilitate^ such  as 
low  diet,  depletion,  purgation,  or  the  use  of  sedatives.  In  a  like  spirit  with 
Trousseau,  that  very  accomplished  English  physician,  Latham,  said  "erysip- 
elas is  a  disease  that  may  be  treated,  but  not  cured;"1  and  Gosselin,  the 
eminent  French  surgeon,  declares  that  "erysipelas  can  be  arrested  by  no 
treatment  whatever."2 

In  ordinary  cases,  then,  of  erysipelas,  that  is  to  say,  in  cases  of  average 

1  Works,  New  Sydenham  Society's  edition,  vol.  ii.  p.  461. 
8  Nouveau  Dictioimaire,  t.  xiv.  p.  30. 


TREATMENT    OF   ERYSIPELAS.  193 

severity,  and  whether  of  the  medical  or  the  surgical  form,  it  is  imperative  that 
the  patient  should,  as  tar  as  possible,  be  isolated;  that  he  should  have  no  more 
attendants  than  are  absolutely  necessary ;  that  his  chamber  should  be  well 
ventilated,  but  without  exposing  him  to  draughts  of  air  or  to  dampness  ; 
that  perfect  cleanliness  should  be  maintained  about  the  wound,  if  there  be 
one ;  and  that  when  the  bed-  and  body-clothing  are  washed,  they  should  be 
thoroughly  scalded  before  being  handled.  The  inflamed  part  should  be 
placed  in  as  comfortable  a  position  as  possible,  and  the  face,  when  affected, 
should  not  be  exposed  to  a  strong  light;  the  skin  should  be  kept  dusted  with 
lycopodium,  or  finely  powdered  starch,  or  wheat  or  rye  flour,  and  covered 
with  carded  cotton;  and  in  cases  attended  with  much  burning  and  tension,  a 
smaller  or  larger  proportion  of  oxide  of  zinc  should  be  mixed  with  the  flour, 
or  the  part  may  be  kept  anointed  with  vaseline,  a  far  better  protective  than 
glycerine  which  has  been  much  used  for  this  purpose.  Vaseline  is  also 
greatly  superior  to  ointments,  for  unlike  them  it  is  not  apt  to  become  rancid, 
and  it  may  serve  as  an  excipient  for  oxide  of  zinc  or  lead,  or  any  anodyne 
extract  which  may  seem  appropriate.  The  white  of  egg  alone,  or  mixed 
with  finely  powdered  alum,  may  also  be  used.  Mucilages  should  never  be 
employed.  The  mucilage  of  slippery  elm,  and  still  more  of  flaxseed,  and 
poultices  made  of  these  substances,  have  to  answer  for  a  great  deal  of  discom- 
fort during  their  application,  and  the  production  of  a  vesicular  or  pustular 
eruption  which  is  unsightly,  painful,  and  sometimes  difficult  to  heal. 

At  a  time  when  every  inflammation  and  fever  was  recognized  as  an  almost 
infallible  indication  for  blood-letting,  it  was  naturally  and  extensively  employed 
in  the  treatment  of  erysipelas,  and  its  use  was  justified  by  names  of  unques- 
tionable authority.  Even  the  candid  and  clear-sighted  Sydenham  advised 
copious  depletion.  But  the  weight  of  judgment  is  on  the  opposite  side. 
According  to  one,  it  is  of  "fatal  tendency;"  others  "always  found  it  hurt- 
fid,"  or  "  rarely  admissible,"  or  "  destructive."  "  It  makes  bad  worse,"  said 
Heberden  ;  "  it  renders  the  disease  more  obstinate  and  severe,"  said  Desault ; 
and  Willan  declared  that  "  in  the  low  forms  it  is  manifestly  improper,  and 
in  the  phlegmonous  not  always  necessary."  According  to  Copland,  "  large 
depletions  should  be  employed  with  much  circumspection,  for  however  high 
the  temperature,  or  hard  and  bounding  the  pulse,  there  is  always  a  dispo- 
sition to  asthenic  vascular  action  and  a  deficiency  of  vital  power;"  and 
Bally  is  of  opinion  that  "  it  tends  to  aggravate  the  symptoms,  bring  on 
and  intensifjr  delirium,  and  prolong  the  attack." 

Yet,  even  half  a  century  ago,  there  were  found  eminent  surgeons  to  say, 
like  Sir  W.  Lawrence,  that,  "as  this  affection  resembles  other  inflammations, 
it  must  be  treated  upon  the  same  principles.  Venesection,  local  bleeding, 
purging,  and  low  diet  are  the  first  measures,  to  which  saline  and  diaphoretic 
medicines  may  be  afterwards  added.  Vigorous  treatment  in  the  beginning 
will  often  cut  the  attack  short."  It  is  true  that  he  qualified  the  rigor  of  this 
method  by  stating  numerous  exceptional  cases  in  which  it  would  be  mis- 
chievous, and  especially  those  of  patients  weakened  by  old  age  or  previous 
disease,  and  he  recognized  its  inappropriateness  after  the  first  stage  of  the 
attack.  Since  his  time,  depletion  having  gone  out  of  fashion,  even  in  the 
treatment  of  sthenic,  inflammatory  diseases,  it  has  naturally  come  to  be 
regarded  as  pernicious  in  those  which,  like  erysipelas,  tend  so  readily  to  a 
typhoid  state.  The  judgments  against  depletion  in  this  disease  are  therefore 
quoted,  not  because  at  the  present  time  any  one  would  probably  be  tempted 
to  adopt  it  as  a  mode  of  treatment,  but  to  serve  as  an  argument  in  favor  of 
the  opposite  method  which  is  advocated  in  this  article.  The  objections  are 
measurably  applicable  to  local  as  well  as  to  general  depletion.  Indeed  in  the 
former,  if  less  injury  is  risked  by  the  loss  of  blood,  much  more  danger  is 

vol.  i. — 13 


194  ERYSIPELAS. 

incurred,  through  the  wounds  made  by  leeching  or  cupping,  of  infecting  the 
system  anew  with  the  erysipelatous  poison,  and  of  creating  a  starting-point 
for  suppuration  or  gangrene.  Such  objections  are  still  weightier  against 
punctures  and  scarifications  employed  to  relieve  the  congestion  of  the  skin 
in  simple  erysipelas,  inasmuch  as  they  form  wounds  which,  besides  this 
special  risk,  answer  their  purpose  as  depleting  agents  very  imperfectly 
indeed.  The  use  of  incisions  in  the  treatment  of  phlegmonous  erysipelas  has 
special  objects  which  will  be  considered  hereafter. 

The  most  ancient  treatment  of  erysipelas  included,  as  has  already  been 
stated,  the  application  of  cold  water  and  other  lotions  to  the  affected  part,  but 
the  dangers  of  the  method,  recognized  even  then,  are  more  generally  acknowl- 
edged now.  We  cannot  therefore  commend  the  practice  of  Luecke,  who,  fol- 
lowing the  example  of  Hebra  and  others,  advises  the  application  of  ice  to  the 
erysipelatous  scalp,  and  declares  that  he  did  not  lose  a  single  patient  out  of  a , 
large  number  treated  by  him  in  this  manner.1  Whether  the  same  result 
would  not  have  been  reached  by  him,  as  it  has  been  by  others,  with  a  purely 
negative  topical  treatment,  may  well  be  questioned.  Indeed,  it  may  be  re- 
marked here,  once  for  all,  that  apart  from  the  surgical  treatment  of  phlegmo- 
nous erysipelas,  local  applications  have  not  the  slightest  influence  upon  the 
course  or  issue  of  the  disease  beyond  that  which  they  exert  as  protectives  and 
palliatives.  This  influence  should  not  be  undervalued,  but  it  ought  not  to 
be  mistaken  for  a  radical  and  curative  action. 

As  palliatives,  then,  may  be  employed  a  variety  of  astringent  and  stimulant 
applications ,  all  of  which  protect  the  inflamed  part  from  the  irritating  action 
of  the  air,  and  either  repress  the  vascular  action  in  it  or  overcome  the  stagna- 
tion of  the  blood  by  quickening  its  circulation.  Of  the  former  description 
are  lime-water  liniment,  alum  curd,  fresh  or  sour  cream,  solutions  of  the  salts 
of  lead  and  zinc,  or  of  the  chloride  or  the  sulphate  of  iron,  or  some  of  these 
salts,  and  especially  the  oxide  of  zinc,  in  powder.  In  France,  a  popular  preju- 
dice regards  all  watery  applications  as  injurious.  The  acetate  of  zinc  has 
been  prescribed  internally,  upon  theoretical  grounds,  and  without  advantage. 
The  carbonate  of  lead  has  been  applied,  mixed  with  linseed  oil,  as  a  paint ;  but 
if  any  lesion  of  the  skin  exists,  it  is  apt  to  be  poisonous.  Flexile  collodion 
has  also  been  used  to  protect  and  constringe  the  affected  skin,  but  is  more 
painful  than  useful  in  all  cases  of  erysipelas  that  really  call  for  active  treat- 
ment. Solutions  of  gutta  percha  and  also  of  salicylate  of  sodium  have  been 
employed  for  the  same  purpose,  and  with  analogous  results.  Mechanical  com- 
pression of  the  affected  part  lias  been  made  by  bandages,  especially  in  surgi- 
cal erysipelas  of  the  limbs.  Velpcau,  who  was  one  of  the  first  to  make  use 
of  it,  limited  its  application  to  cases  in  which  the  inflammation  did  not  extend 
deeply  beneath  the  skin,  and  perhaps,  like  the  astringents  already  noticed,  it 
tended  to  retard  or  limit  the  inflammation.  But  the  impossibility  of  antici- 
pating the  future  course  of  any  such  affection,  and  the  great  danger  of  the 
]  »arts  swelling  beneath  their  bandages  so  as  to  produce,  as  actually  happened 
in  several  cases,  not  only  excessive  pain,  but  ulceration  and  gangrene,  suffice 
to  condemn  this  method  which,  in  reality,  was  the  product  of  crude  theory 
and  not  of  clinical  experience. 

Another  method  of  local  treatment  consists  in  the  application  of  stimulants 
to  the  inflamed  part.  One  of  the  first  used  .of  these  was  a  blister,  the  extent 
of  which  was  limited  only  by  that  of  the  erysipelas.  Cases  are  on  record  in 
which  it  was  made  to  envelop  an  entire  limb  ;  and  although,  as  usually  hap- 
pens to  medicinal  agents,  its  novelty  brought  it  some  applause,  and  not  a 
little  false  credit,  its  condemnation  was  not  slow  to  follow,  for  the  demon- 

1  Neftel,  Medical  Record,  vol.  iv.  p.  79. 


TREATMENT    OF    ERYSIPELAS.  195 

stration  of  its  good  and  evil  results  was  not  difficult.  Subsequently,  blisters 
were  applied  around  limbs  affected  with  erysipelas,  not  upon  the  inflamed 
portion,  but  upon  the  sound  skin  at  a  little  distance  from  the  latter,  and  were 
believed  to  prevent  the  extension  of  the  disease  in  that  direction ;  but  expe- 
rience has  shown  that  this  belief  was  delusive,  and  that  erysipelas  pays  no 
respect  to  any  such  barriers  in  its  path.  Almost  identical  with  fly-blisters  in 
its  mode  of  operation  in  this  disease  is  a  strong  solution  of  nitrate  of  silver,  for 
which  a  claim  was  long  ago  made,  and  more  recently  renewed  by  its  proposer, 
Du.  Iligginbottom,  that  it  absolutely  arrested  the  progress  of  the  disease. 
The  total  loss  of  faith  in  this  vaunted  remedy,  which  was  not  only  painful  but 
inefficacious,  is  another  fact  among  the  many  which  prove  that  erysipelas  is  as 
little  to  be  cured  as  smallpox  by  remedies  applied  to  the  skin.  Of  agents 
belonging  to  this  class,  iodine  is  one  of  the  best.  It  has,  of  course,  an  array  of 
' "  cures"  in  its  favor ;  but  it  is  certainly  a  valuable  palliative  of  the  pain  and 
swelling  in  some  cases  of  erysipelas,  especially  of  the  face.  The  compound 
solution,  or  the  compound  tincture,  should  be  painted  on  the  inflamed  part. 

It  is  unnecessary  to  discuss  the  value  of  the  actual  cautery,  or  the  moxa, 
which  have  been  vaunted  by  certain  surgeons  in  this  disease ;  they  are  as 
cruel  as  they  are  useless.  As  a  substitutive  and  protective  agent,  the  liniment 
of  turpentine,  or  Kentish's  ointment,  is  a  very  convenient  palliative  of  the  local 
symptoms  in  cases  of  superficial  erysipelas,  and  has  long  been  used  for  that 
purpose.  More  recently  (1869),  Luecke1  conceived  that  it  had  a  specific 
power  of  destroying  the  hypothetical  virus  of  erysipelas.  Another  medicine 
whose  mode  of  action  was  conceived  to  be  similar,  is  hyposulphite  of  sodium, 
and  its  curative  powers  were  attested  by  several  physicians  and  surgeons  of 
established  reputation.  But  as  the  success  of  the  medicine  was  said  to  be 
just  as  great  whether  it  was  employed  internally  or  topically,  we  may  fairly 
conclude  that  its  virtues  were  more  apparent  than  real,  an  inference  which  is 
quite  confirmed  by  the  complete  neglect  into  which  it  has  fallen  since  its  first 
introduction,  about  1860.  A  like  estimate  which  has  been  made  of  iodide  of 
calcium,  probably  calls  for  a  similar  criticism.  Among  the  topical  applica- 
tions used  in  this  disease,  camphor  may  be  mentioned,  which  is  anodyne,  and 
when  used  in  alcoholic  solution  and  allowed  to  evaporate,  is  also  somewhat 
cooling.  At  one  time  mercurial  ointment  was  held  by  some  authorities  to  be 
almost  certain  to  arrest  the  inflammation  and  extension  of  erysipelas ;  but 
such  effects  were  soon  found  to  be  uncertain,  if  not  unreal,  while  the  frequent 
occurrence  of  salivation  after  the  mercurial  inunction  led  to  its  general  dis- 
use. That  it  cures  cases  of  the  disease  which  would  not  get  well  spontane- 
ously, cannot  be  admitted.  Finally,  it  may  be  mentioned"  that  bromine  has 
been  used  in  watery  solution,  as  a  lotion.  As  far  as  it  is  useful  in  superficial 
erysipelas,  it  may  be  supposed  to  act  as  a  local  stimulant  and  anodyne.  In 
phlegmonous  erysipelas,  when  an  opening  exists,  and  especially  when  slough- 
ing of  the  cellular  tissue  takes  place,  a  solution  of  bromine  may  be  used  as  a 
stimulant  and  disinfectant. 

Surgical  Treatment. — The  surgical  treatment  proper  of  erysipelas,  relates 
mainly  to  the  management  of  those  cases  of  the  phlegmonous  form  of  the 
disease  in  which  openings  must  be  made  through  the  skin,  to  give  exit  to 
dead  connective  tissue  and  the  liquid  products  of  inflammation;  but  it  also 
relates  to  that  of  the  wound  which  is  the  starting-point  of  the  attack.  But 
often  the  inflammation  forms  bullae,  or  abscesses,  which  are  of  limited  extent, 
and  do  not  require  any  other  treatment  than  would  be  appropriate  in  the  ab- 
sence of  erysipelas,  viz.,  the  evacuation  of  the  blebs  and  abscesses,  and  their 

1  Bulletin  de  Therapentique,  t.  lxxvi.  p.  422. 


196  ERYSIPELAS. 

dressing  with  wet  compresses  or  poultices,  or  with  dry  astringent  powders, 
or  with  salves.  The  same  applications  are  suitable  when  superficial  sloughs 
occur.  As  such  sloughs  often  form  upon  parts  the  integument  of  which 
is  delicate,  as  upon  the  eyelids,  the  ears,  and  the  genital  organs,  if  this 
accident  appears  to  be  due  to  the  tension  of  the  part  more  than  to  the  deli- 
cacy of  the  skin,  it  is  generally  prudent  to  diminish  the  pressure  by  punc- 
tures or  incisions  that  will  give  issue  to  the  subjacent  liquid.  When 
phlegmonous  inflammation  of  the  coimective  tissue  takes  place,  it  is  the 
usual  practice,  if  not  always  necessary,  to  make  openings  through  which  the 
products  of  inflammation  can  escape.  This  may  sometimes  be  effected  by 
jmnctures,  or  more  thoroughly  by  free  incisions  (Copland  Hutchison),  at  the 
most  convenient,  depending  point  of  the  swelling;  but  not  unless  the  tension 
of  the  part,  its  painfulncss,  the  tendency  of  the  suppuration  to  advance,  or 
the  threatening  of  gangrene,  furnishes  the  indication  for  interference. 

Punctures  were  highly  recommended  more  than  half  a  century  ago  by 
Dobson,  who  employed  them  in  all  cases,  in  number  from  ten  to  fifty,  and 
varying  in  depth  from  two  to  four-tenths  of  an  inch,  repeating  them  from 
two  to  four  times  in  the  twenty-four  hours,  and  on  the  scalp,  face,  trunk,  or 
extremities,  as  occasion  required.  He  contended  that  not  only  were  the  in- 
teguments better  preserved  by  making  several  small  openings  than  by  one 
large  incision,  but  that  the  effused  matter  was  quite  as  well  evacuated.1  It 
may  be  objected  to  this  method  that  it  involves  a  very  unnecessary  suffering 
in  all  forms  of  erysipelas,  except  the  phlegmonous,  since  they  spontaneously 
tend  to  recovery ;  and  at  the  time  of  its  original  proposal,  it  was  said  not  to 
be  adapted  to  the  phlegmonous  form.  It  was,  however,  a  mild  procedure  in 
comparison  with  that  of  Lawrence,  for  which  it  was  proposed  as  a  substitute, 
and  which  consisted  in  "  making  incisions  through  the  inflamed  skin  and  the 
subjacent  adipose  and  cellular  textures,"  which  were  sometimes  of  appalling 
length.  In  one  case,  it  is  said,  "  an  incision  was  made  from  the  ham  to  the 
heel,"  and  in  another,  involving  the  forearm,  the  cuts  "  extended  nearly  the 
length  of  the  limb."  The  method  by  punctures,  and  that  by  short  incisions, 
seem  to  be  quite  sufficient  for  all  the  exigencies  of  this  disease.  The  former 
is  said  to  be  adapted  to  its  early  stages ;  but,  as  already  suggested,  the  neces- 
sity of  the  procedure  is  so  far  from  apparent,  that  it  would  seem  to  be  called 
for  only  in  exceptional  circumstances.  In  the  brawny  stage  of  the  inflam- 
mation, it  is  recommended  that  "  incisions  from  one  to  two  inches  long,  and 
two  or  three  inches  apart,  should  be  made  over  the  inflamed  surface,  in  the 
general  direction  of  the  subjacent  muscular  fibres  "  (Ashhurst),  and  on  alter- 
nate   lines,   thus  |       |    ,  "  the  greatest   relief  from  tension  being  thus  ob- 

tained  with  the  least  destruction  of  tissue."  "At  a  later  stage,  when  braw- 
niness  has  given  place  to  bogginess,  showing  that  sloughing  of  the  subcuta- 
neous tissues  has  already  occurred,  free  and  deep  incisions,  three  or  four 
inches  long,  may  be  required,  in  order  to  prevent  gangrene  of  the  skin,  and 
to  afford  exit  for  sloughs,  the  separation  of  which  may  be  hastened  by  the 
forceps  and  scissors.  Warm  fomentations  should  be  constantly  applied, 
and  antiseptics  may  be  freely  used,  not  only  in  the  dressings,  but  injected 
among  die  (issues  by  syringing.  When  the  suppuration  is  very  profuse,  the 
fomentation  may  be  omitted,  the  part  being  simply  covered  with  lint  and 
charpie,  tow,  oakum,  or  carded  cotton,  and  supported  by  the  gentle  pres- 
sure of  a  bandage"'  (Ashliurst).  When  there  is,  as  is  most  apt  to  be  the  case 
in  traumatic  erysipelas,  even  less  tendency  to  circumscription  of  the  disease, 

Medico-Chirurgical  Review,  Auguat,  182S,  p.  383. 


TREATMENT    OF    ERYSIPELAS.  197 

and  from  the  first  the  part  is  soft  as  well  as  greatly  swollen,  and  the  type  of 
the  attack  typhoidal,  such  incisions  as  have  been  described  are  imperatively 
necessary  to  lessen  the  danger  of  gangrene  of  the  skin,  and  to  furnish  an  outlet 
for  the  products  of  decomposition.  "In  the  scalp,  crucial  incisions  are  the 
most  effective,  while  in  the  scrotum  a  single  free  incision  on  either  side  of 
the  raphe  will  usually  be  all  that  is  neeesssary."  When  the  eyelids  are  much 
swollen,  it  is  prudent  to  incise  them  parallel  to  their  folds,  to  prevent  puru- 
lent collections.  If  the  eyeball  becomes  very  prominent,  and  there  is  rea- 
son to  believe  that  pus  is  infiltrated  behind  it,  a  deep  incision  of  the  soft 
parts  that  line  the  floor  of  the  orbit  is  called  for,  and  a  blunt  probe  or  direc- 
tor should  be  introduced  to  the  supposed  seat  of  the  pus,  to  guide  the  blade 
of  a  lancet  or  bistoury,  held  flatwise. 

Besides  the  use  of  carbolic  acid  as  a  dressing  in  the  proper  surgical  cases 
above  noticed,  it  has  been  employed  in  different  manners.  Thus  it  is  stated 
by  Zuelzer1  that  Kaczorowski  applied  to  the  inflamed  surface  a  mixture  of 
one  part  of  carbolic  acid  and  ten  of  oil  of  turpentine,  which,  after  temporarily 
irritating  the  skin,  subdued  its  inflammation  in  a  marked  degree  ;  that  AVilde 
injected  subeutaneously  into  the  inflamed  part  a  solution  of  sulpho-carbolate 
of  sodium  (1 :  12);  and  that  Iluter  employed  a  three  per  cent,  solution  of  car- 
bolic acid  in  the  same  manner.  Tillmanns's  experiments  led  him  to  the  conclu- 
sion that  a  carbolic  acid  solution  (2  to  4  per  cent.)  rendered  a  previously  active 
erysipelatous  inoculating  liquid  quite  inoperative,2  and  he  has  more  recently 
recommended  the  hypodermic  injection  of  a  similar  solution  around  the  limits 
of  the  affected  skin  in  the  earliest  stages  of  the  inflammation.  This  mode  of 
treatment  is  said  to  cause  no  pain,  and  to  render  the  skin  pale  and  wrinkled.3 
Tassi  claims  to  have  cured  four  cases  of  erysipelas  by  means  of  a  saturated 
solution  of  the  acid  employed  in  the  same  manner.4  Eothe  attributes  to  the 
following  lotion  a  mitigation  of  the  inflammation  in  duration  and  severity : 
R.  Acid,  carbolic,  gr.  xv ;  alcohol,  tij,xv;  ol.  terebinthinse,  f 3ss ;  tr.  iodinii, 
nixv;  glj-cerinre,  f3iss.  M.  "With  this  the  part  should  be  bathed  every  two 
hours,  and  kept  covered  with  cotton-wool.  Dr.  S.  J.  Radclifte  has  reported 
the  case  of  a  very  old  and  feeble  woman,  in  whom  erysipelas,  beginning  at  a 
bunion  on  the  foot,  extended  to  the  whole  of  the  lower  extremity,  producing 
enormous  swelling,  and  attacked  the  buttock  where  it  occasioned  an  eschar. 
After  the  total  failure  of  local  protectives  and  of  the  internal  use  of  iron  and 
quinia,  he  applied  a  solution  (1 :  16)  of  carbolic  acid  in  olive  oil,  three  times  a 
day,  covering  the  part,  also,  with  cotton-wool.  Relief  was  obtained  almost 
immediately,  the  local  phenomena  rapidly  declined,  and  the  patient  recovered.5 
Dr.  A.  G.  Miller,  of  Edinburgh,  while  inclined  to  regard  as  useful  the  internal 
employment  of  sulpho-carbolate  of  sodium,  and  that  of  the  carbolates  of  so- 
dium and  quinia,  refers  to  their  irritant  effects.,  and  especially  those  of  the 
latter  preparations,  upon  the  stomach  and  bladder.6 

The  internal  medication  of  erysipelas  in  ancient  times  consisted,  as  we  have 
seen,  chiefly  in  the  use  of  purgatives,  which  were  believed  to  be  cholagogue, 
and  which  appeared  to  be  indicated  by  the  gastric  derangement  which  is  the 
usual  accompaniment  of  the  first  stage  of  febrile  affections  in  warm  climates. 
In  recent  times,  emetics  have  been  more  generally  employed  for  a  similar  pur- 
pose, and  perhaps,  by  the  shock  which  they  give  the  system,  to  break  up 

1  Ziemssen,  loc.  cit.  2  Edinburgh  Medical  Journal,  vol.  xxv.  p.  Gu7. 

3  Philadelphia  Medical  Times,  January,  1881,  p.  201, 

4  Bulletin  de  Therapeutique,  t.  c.  p.  239. 

6  Philadelphia  Medical  Times,  vol.  xi.  p.  455. 
6  Edinburgh  Medical  Journal,  vol.  xxv.  p.  1095. 


198  ERYSIPELAS. 

"the  chain  of  morbid  associations,"  to  use  the  figurative  hut  not  unmeaning 
phrase  of  another  epoch.  However  this  may  he,  the  frequent  occurrence  of 
spontaneous  vomiting  was  supposed  to  indicate  a  biliary  derangement,  and 
"a  saburral  condition"  of  the  stomach,  and  this  belief  was  confirmed  by  the 
accompanying  thick  coating  upon  the  tongue.  But  now  it  is  certain  that 
vomiting  is  a  frequent  precursor  of  febrile  attacks  of  very  diverse  nature,  and 
that  the  degree  and  nature  of  the  tongue's  coating  is  immediately  related  to 
the  general  state  of  the  system,  and  not  at  all  to  that  of  the  stomach.  Al- 
though the  reasons  given  for  an  emetic  treatment  of  erysipelas  may  have  been 
groundless,  the  method  itself  may  have  been  good,  by  as  much  as  facts  are 
generally  better  than  opinions,  and  practice  than  theory.  It  may  very  well 
be  that  an  emetic  or  an  emeto-cathartic  given  in  the  forming  stage  of  this  as 
well  as  of  many  other  febrile  diseases,  will  tend  to  mitigate  its  severity  and 
modify  its  course,  partly  by  cleansing  the  alimentary  canal  of  its  putrescible 
contents,  and  partly  by  quickening  all  the  eliminative  secretions,  and  very 
possibly  by  expelling  in  this  manner  a  portion  of  the  morbid  poison  contained 
in  the  blood.  It  is  a  treatment  which  may  be  eligible  without  being  elegant, 
and  that  it  is  the  former,  our  experience,  especially  in  hospitals,  does  not  per- 
mit us  to  doubt.  The  most  appropriate  emetic  is  ipecacuanha,  the  most 
unsuitable,  as  a  rule,  is  tartar  emetic ;  or,  if  the  latter  be  used,  it  should  be 
prescribed  in  small  doses  dissolved  in  a  weak  solution  of  Epsom  salt  or  some 
analogous  saline.  The  emetic  treatment,  it  need  hardly  be  added,  is  not  so 
well  adapted  to  surgical  as  it  is  to  medical  erysipelas. 

The  use  of  alcoholic  stimulants,  in  ordinary  cases  of  the  disease,  is  not  only 
unnecessary  but  injurious,  for  they  increase  the  fever,  lessen  the  appetite  for 
food,  and  impair  the  digestive  function.  It  was  part  of  a  system  of  stimula- 
tion which  Dr.  Todd,  of  London,  brought  into  vogue  about  1860,  to  administer 
in  this  disease,  at  stated  times  and  in  small  doses,  so  as  not  to  excite  nausea 
and  intolerance,  beef-tea  and  brandy.  He  even  went  so  far  as  to  say,  "  If  I 
were  restricted  to  one  remedy  in  this  disease,  I  should  assuredly  choose 
brandy."1  And  he  repeated  and  elaborated  this  idea  in  his  clinical  lectures 
published  four  years  later.  Considering  that  he  had  to  do  with  neither  sur- 
gical (traumatic)  nor  puerperal  erysipelas,  it  is  certain  that  he  went  far  beyond 
either  his  contemporaries  or  his  successors,  in  his  recommendation.  Nothing 
can  be  more  certain  than  that  erysipelas,  as  such,  stands  in  no  need  of  alcoholic 
treatment ;  but  that  the  typhoid  forms  and  states  of  the  disease  may  and 
generally  do  call  for  it,  as  the  same  conditions  do  in  all  other  febrile  affections, 
is  unquestionable.  And  not  only  for  alcohol  but  for  other  stimulants,  cardiac 
and  nervous,  of  which  oil  of  turpentine  is  by  many  ranked  highest,  as  it  is  also 
in  whatever  form  of  fever  a  tendency  to  the  typhoid  state  is  most  marked ; 
and  next  to  it,  or  even  higher  but  for  its  more  transient  operation,  carbonate 
of  ammonium  may  be  placed. 

]STot  many  years  ago,  the  prevalent  theory  of  erysipelas  attributed  its  phe- 
nomena directly  to  the  extravasation  of  the  white  corpuscles  of  the  blood, 
and,  as  at  that  time  quinia  became  endowed  with  a  specific  control  over  this 
migration,  it  was  looked  upon  as  the  natural  antidote  of  erysipelas.  But  as 
the  theory  could  not  be  made  to  embrace  all  of  the  cases  in  which  the  utility 
of  quinia  had  been  demonstrated,  another  virtue  was  assigned  to  it,  viz., 
that  of  destroying  disease-germs;  and,  finally,  this  being  found  an  inadequate 
explanation,  the  antipyretic  virtues  of  quinia  were  invoked  to  account  for  its 
power  in  curing  erysipelas.  It  was  omitted,  however,  to  show  that  in  any 
true  and  real  sense  quinia  did  cure,  i.e.,  arrest,  this  disease.  It  is  claimed 
that  the  use  of   large  doses  of  quinia  in  erysipelas  was  instituted,  in  this 

1  Medical  Times  and  Gazette,  January,  1855,  p.  29. 


TREATMENT    OF   ERYSIPELAS.  199 

country  at  least,  by  Surgeon  Satterlee,  IT.  S.  A.,  as  long  ago  as  the  Florida 
Indian  war,  in  1835.  In  1836,  Latham1  claimed  that  in  certain  cases  the 
patients  must  have  died  without  quinia,  and  that  it  "  cured  them  outright, 
without  the  fulfilment  of  any  intermediate  purpose  whatever;"  and  he  recalled 
the  fact  that  at  the  beginning  of  the  present  century  bark  was  regarded  by 
all  experienced  physicians  as  a  specific  for  erysipelas.  Indeed  it  was  pre- 
scribed by  Ileberden,  Hoffman,  Fordyce,  Pearson,  Cooper,  and  many  others, 
to  control  a  tendency  toward  the  typhoid  state  so  charaeteristic  of  this 
disease.  In  1857,  Coale  prescribed  ten  grain  doses  of  quinia  in  pharyngeal 
erysipelas.2  More  recently,  quinia  has  been  employed  for  quite  a  different 
purpose,  viz.,  in  such  doses  as  to  produce  a  sedative  impression.  In  1874,  Dr. 
F.  Satterlee  reeommended  the  administration,  in  the  forming  stage  of  the 
attack,  of  sulphate  of  quinia  in  doses  of  twenty-five  or  thirty  grains,  but  if 
the  disease  was  fully  developed,  lie  directed  a  similar  dose  every  night  for 
three  successive  times.  He  claimed  that  in  some  cases  a  single  one  of  the 
doses  mentioned  proved  sufficient  to  abort  the  attack,  while  in  other  instances 
the  temperature  and  pulse  fell  greatly,  and  the  general  symptoms  either  dis- 
appeared or  improved,  from  twenty-four  to  forty-eight  hours  sufficing  to 
abort  the  disease.3  Binz  and  Liebermeister  have  also  used  this  method  with 
like  results.  It  may  be  added  to  these  statements,  without  attributing  to  it 
great  weight,  that,  according  to  Rombla,  hydrobromate  of  quinia,  employed 
hypodermically,  caused  a  rapid  subsidence  of  the  symptoms  in  a  case  of 
typhoid  erysipelas.4  It  will  be  observed  that  equal  success  is  claimed  for 
quinia,  whether  it  is  given  in  small  or  tonic  doses,  or  in  massive,  sedative, 
or  so-called  antipyretic  doses.  Theory  apart,  it  must  be  believed  that  the 
former  are  most  appropriate  in  the  epidemic  and  typhoid  forms  of  the 
disease,  and  the  latter  in  the  more  sthenic  cases,  of  which  erysipelas  of  the 
face,  as  it  ordinarily  occurs,  may  be  taken  as  the  type. 

Tincture  of  chloride  of  iron  was,  at  one  time,  regarded  as  almost  a  specific, 
at  least  in  the  idiopathic  forms  of  erysipelas.  In  1851,  Mr.  G.  II.  Bell,  of 
Edinburgh,  declared  that  for  twenty-five  years  he  had  made  use  of  it  without 
having  in  a  single  instance  tailed  of  success.  In  mild  cases  he  prescribed 
fifteen  drops,  and  in  severe  cases  twenty-five  drops,  of  the  medicine  every  two 
hours,  night  and  day,  however  high  the  fever  and  delirium,  until  the  disease 
was  completely  removed.  These  conclusions  were  confirmed  by  C.  Bell  and 
others.  In  1852,  Begbie  related  several  cases  in  which  the  exhibition  of  the 
medicine  was  quickly  followed  by  a  remission  of  all  the  symptoms.5  Pirrie 
stated,  that  under  its  use,  "  the  febrile  condition  seemed  to  be  relieved, 
the  frequency  of  the  pulse  reduced,  the  powers  of  the  system  generally  to 
be  upheld,  and  the  stomach  and  bowels  in  no  way  irritated.  Headache  and 
sensorial  disturbance  diminished  under  its  use."  He  prescribed  15  to  20 
drops  every  two  or  three  hours,  until  convalescence  was  fairly  established.6 
In  France  it  was  used  soon  afterwards  by  Aran,  Mathey,  and  others.  Ac- 
cording to  Mathey,  by  the  third  day  after  the  medicine  was  commenced, 
often  by  the  second,  or  even  by  the  first  day,  the  progress  of  the  disease  was 
checked.  He,  however,  prescribed  not  more  than  thirty  drops  a  day  ;  but 
Aran  increased  the  dose  to  twice  or  three  times  as  much,  or  even  more  than 
this,  and  obtained  equally  satisfactory  results.  He  conceived  that  certain 
cases  were  not  benefited  by  this  treatment,  especially  those  occurring  in  young 

1  Op.  eit.,  p.  401. 

2  Boston  Medical  and  Surgical  Journal,  February,  1857,  p.  63. 
8  New  York  Medical  Journal,  vol.  xx.  p.  579. 

4  Compendium  de  Therapeutique,  1880,  p.  83. 

6  Monthly  Journal  of  Medical  Science,  September,  1S52,  p.  243. 

6  Edinburgh  Medical  Journal,  July,  1861. 


200  ERYSIPELAS. 

and  healthy  persons  of  a  sanguine  temperament,  and  that  it  was  most  efficient 
when  the  patients  were  of  a  delicate,  feeble,  lymphatic  constitution,  or  Lad 
been  exhausted  by  previous  disease,  when  the  local  inflammation  was  (edema- 
tous rather  than  phlegmonous,  the  pulse  soft  rather  than  tense,  and  the  tem- 
perature not  very  high.  It  appeared  to  be  most  useful  in  the  milder  and  more 
superficial  forms  of  traumatic  erysipelas,  in  the  chronic  and  wandering  forms, 
in  a  word,  in  all  that  involved  debility  of  the  system.  It  would  seem,  also,  to 
have  been  successfully  used  as  a  prophylactic  for  persons  about  to  be  operated 
upon  in  surgical  wards  where  erysipelas  prevailed.1 

As  late  as  1880,  the  utility  of  tincture  of  chloride  of  iron  in  this  disease 
was  still  recognized  in  Edinburgh,  for  it  is  stated  by  Miller  that  in  the  Royal 
Infirmary  in  that  city  the  ordinary  treatment  of  erysipelas  consisted  of  a 
purge,  milk  diet,  and  the  iron  tincture,  with  a  dressing  of  flour  and  cotton- 
wadding.  Its  effect  on  the  milder  cases  was  manifested  in  a  few  hours  inva- 
riably. With  these  statements  the  experience  of  the  writer  substantially 
agrees,  and  while  the  measure  of  the  medicine's  utility  is  not  always  the  same, 
it  appears  to  him  none  the  less  prompt  and  decided,  although  most  unequivo- 
cally so  in  the  less  sthenic  forms  of  the  disease.  The  impression  he  has  re- 
ceived from  his  experience  is  that  this  preparation  has  a  double  mode  of  action  ; 
that  it  acts  by  constringing  the  bloodvessels,  and  thereby  limiting  the  inflam- 
matory process,  and  that  while  it  tends  to  maintain  the  normal  constitution 
of  the  blood,  it  also  counteracts  the  noxious  operation  of  the  poison  in  the 
system. 

It  is  proper,  however,  to  state  that  a  less  favorable  judgment  has  been  pro- 
nounced by  some  clinical  observers.  Long  ago,  Todd,  prepossessed,  no  doubt, 
in  favor  of  his  own  stimulant  method,  considered  that  the  iron  might  be  use- 
ful in  otherwise  benign  cases,  partly  and  chiefly  because  it  excluded  depress- 
ing treatment.  "But,"  he  added,  "  I  would  as  soon  think  of  trusting  to  it  in 
the  treatment  of  grave  cases,  as  I  would  to  the  billionth  of  a  grain  of  aconite, 
or  of  arnica,  or  sulphur,  or  any  other  homoeopathic  absurdity  ;"2  but  five  years 
later  he  softened  this  contemptuous  judgment  by  the  advice  not  to  trust  to 
the  medicine  alone,  "  but  merely  to  use  it  as  an  adjunct  to  the  stimulant  regi- 
men."3 Nortel  was  not  very  happy  in  declaring  that  the  medicine  "  ought  to 
be  entirely  discarded  from  the  treatment  of  erysipelas,  for,  like  all  the  pre- 
parations of  iron  it  increases  the  temperature,  and  is  therefore  injurious  in 
febrile  diseases."4  The  question  is  not  whether  iron  raises  the  temperature, 
but  whether  this  preparation  of  it  tends  to  cure  erysipelas.  Estlander  pro- 
nounced it  to  be  of  no  real  utility  ;5  and  Dr.  R.  J.  Lee  concluded  that  cases 
treated  with  it  were  of  longer  duration  than  usual.6  But  the  weight  of  tes- 
timony  upon  the  subject  is  altogether  against  these  objectors. 

It  would  be  easy  to  enumerate  many  other  medicines  than  the  few  which 
have  been  mentioned,  and  which  have  been  set  forth  as  possessing  a  really 
modifying  and  curative  influence  in  this  disease,  but  as  a  type  of  them  may 
be  given  "the  following  conclusion  respecting  one  of  them,  by  a  writer  upon 
the  subject:  "  It  is  difficult  to  decide  which  is  the  best  treatment,  but  experi- 
ence seems  to  point  to  bicarbonate  of  soda,  largely  diluted  with  water,  to  be 
drunk  warm."7  Such  conclusions  indicate  how  great  is  the  incompetency  of 
some  observers  to  judge  of  the  operation  of  medicines. 

1  Bulletin  do  The'rapeutique,  t.  liii.  p.  12. 

2  Medical  Times  and  Gazette,  July,  1855,  p.  30. 

3  Clinical  Lectures,  18G0,  p.  216. 
*  Medical  Record,  vol.  iv.  p.  78. 

6  Medical  Times  and  Gazette,  December,  1871,  p.  71 G. 

6  Practitioner,  vol.  viii.  p.  158. 

7  Braithwaite's  Retrospect,  Quarterly  Epitome,  1880,  p.  171. 


TREATMENT    OF    ERYSIPELAS.  201 

In  erysipelas  of  infants  at  birth  no  treatment  is  of  much  avail, but  it  necessa- 
rily must  consist  mainly  of  topical  agents,  such  as  have  been  enumerated  for 
the  disease  as  it  occurs  at  a  later  age.  Of  these,  oxide  of  zinc  and  mercurial 
ointments  are  most  generally  recommended.  When  erysipelas  affects  persons 
at  the  opposite  extremity  of  life,  the  only  modification  of  the  ordinary  treat- 
ment should  consist  in  the  tree  hut  judicious  administration  of  alcoholic 
stimulants,  and  of  the  preparations  of  hark  in  tonic  and  stimulant  doses. 
When  the  disease  commences  in  the  fauces,  or  extends  into  the  tarnyx,  these 
parts  should  he  treated  with  astringents  (nitrate  of  silver,  chloride  or  sulphate 
of  iron),  which  may  be  applied  by  means  of  a  swab  or  brush,  or,  still  better,  by 
means  of  the  steam  atomizer,  which  is  equally  appropriate  when  the  inflam- 
mation invades  the  bronchia.  If  the  swelling  of  the  mucous  membrane  of 
the  larynx  interferes  with  respiration,  it  should  be  scarified,  and,  if  this  pro- 
cedure fail  to  give  relief,  the  operation  of  tracheotomy  remains  as  a  last  re- 
source. It  is  possible  that  a  large  blister  on  the  chest  might  be  of  service, 
but  the  evidence  of  its  virtues  is  not  conclusive. 

It  is  unnecessary  in  this  article  to  discuss  in  detail  the  treatment  of  epi- 
demic erysipelas,  or  even  of  those  typhoid  states  of  the  disease  in  its  sporadic 
form  which  are  occasionally  met  with.  As  in  all  similar  cases,  the  treatment 
of  the  local  affection  must  be  subordinated  to  the  type  of  the  attack,  that  is 
to  say  to  the  treatment  of  the  typhoid  state.  In  carrying  out  this  idea,  the 
practitioner  must  not  be  misled  by  the  delirium,  etc.,  into  believing  that  a 
meningitis  exists,  for  no  lesions  representing  that  disease  are  ever  found  after 
death.  The  most  efficient  remedies  are  alcohol  and  opium,  or,  for  the  former, 
coffee  may  he  substituted,  and  quinia  in  small  and  repeated  doses  should 
be  given,  while  stimulating  food  is  not  omitted.  As  in  other  typhoid  affec- 
tions, serpentaria,  ammonia,  camphor,  musk,  etc.,  may  be  useful.  In  this 
form  of  the  disease,  good  nursing  is  of  primary  importance,  and  includes  not 
only  the  h}Tgienic  measures  that  have  been  pointed  out,  but  the  watchful  and 
judicious  administration  of  stimulants,  tonics,  and  food,  as  they  may  be  re- 
quired by  the  varying  condition  of  the  patient. 


PYEMIA  AND  ALLIED  CONDITIONS. 

BY 

FRANCIS  DEL  AFIELD,  M.D., 

ADJUNCT  PROFESSOR  OF  PATHOLOGY  AND  PRACTICAL  MEDICINE  IN  THE  COLLEGE  OF  PHYSICIANS  AND 
SURGEONS,   MEDICAL  DEPARTMENT  OF  COLUMBIA  COLLEGE,   NEW  YORK. 


Nomenclature. 

It  has  long  been  known  that  a  certain  number  of  patients,  who  have  re- 
ceived wounds  by  accident,  or  by  the  hands  of  the  surgeon,  may  sutler  from 
general  constitutional  symptoms  of  greater  or  less  severity.  To  designate 
the  condition  of  these  patients,  the  terms  pyaemia,  septicaemia,  septico-pyaemia, 
ichorrhaemia,  inflammatory  fever,  surgical  fever, traumatic  fever,  suppurative 
fever,  purulent  infection,  etc.,  have  been  used.  These  terms,  however,  are 
used  in  different  ways  by  different  authors.  At  first  the  tendency  was  to 
group  all  these  conditions  together.  Since  1848,  however,  pyaemia  and  septi- 
caemia have  been  distinguished  as  different  conditions.  At  the  present  time 
many  different  views  prevail. 

Billroth  defines  septicaemia  to  be  "a  constitutional, generally  acute  disease, 
which  is  due  to  the  absorption  of  various  putrid  substances  into  the  blood, 
and,"  he  adds,  "  it  is  thought  that  these  act  as  ferments  in  the  blood,  and  spoil 
it  so  that  it  cannot  fulfil  its  physiological  functions."  Pyaemia  is  "a  disease 
which  we  suppose  to  be  due  to  the  absorption  of  pus  or  its  constituents  into 
the  blood."  Hueter  says  "  septicemic  fever  is  produced  by  the  entrance  of 
products  of  putrefaction  into  the  blood.  It  is  possible  that  the  products  of 
putrefaction  are  of  different  kinds,  and  that  consequently  there  are  different 
varieties  of  septicaemia."  He  defines  pyaemia  as  follows:  "Pyemic  fevers  are 
developed  by  the  introduction  into  the  blood  of  the  components  of  pus,  either 
the  serum  or  the  pus  globules.  The  pus  may  enter  directly  into  the  blood- 
vessels or  lymphatics,  or  it  may  first  form  parts  of  thrombi  in  the  veins,  and 
then  enter  the  circulation,  carried  in  the  fragments  detached  from  these 
thrombi."  He  distinguishes  simple  pyaemia  from  metastatic  pyaemia,  and  he 
also  admits  of  a  combination  of  pyaemia  and  septicemia,  which  he  calls  sep- 
ticopyemia. Burdon  Sanderson  says:  "What  I  mean  by  septicemia  is  a 
constitutional  disorder  of  limited  duration,  produced  by  the  entrance  into 
the  blood  stream  of  a  certain  quantity  of  septic  material.  It  must,  there- 
fore, be  regarded,  not  so  much  as  a  disease  as  a  complication,  differing  from 
pyaemia,  not  only  in  the  fact  that  it  has  no  necessary  connection  with  any 
local  process,  either  primary  or  secondary,  but  also  in  the  important  particu- 
lar that  it  has  no  development.  Pyemia  is  a  malignant  process,  which  goes 
on  and  on  to  its  fatal  end ;  but  in  the  case  of  septicemia,  inasmuch  as  the 
poison  which  produces  it  has  no  tendency  to  multiply  in  the  organism,  there 
is  no  reason  why  the  morbid  process  should  not  come  to  an  end  of  itself,  un- 
less either  the  original  dose  is  fatal,  or  a  second  infection  takes  place  from  the 

(203) 


204  PYEMIA    AND    ALLIED    CONDITIONS. 

same  or  another  source."  Mr.  Savory,  speaking  in  the  debate  on  pyaemia  at. 
the  Clinical  Society  of  London  in  1874,  classes  septicaemia  and  pyaemia  to- 
gether as  but  different  degrees  of  effect  of  the  same  poison.  The  London 
Royal  College  of  Physicians  defines  pyaemia  to  he  "  a  febrile  affection  result- 
ing in  the  formation  of  abscesses  in  the  viscera  and  other  parts."  Ordinary 
usage,  at  the  present  day,  applies  the  term  pyaemia  to  those  cases  in  which 
infarctions,  abscesses,  and  local  inflammations  are  present;  while  the  term 
septicaemia  is  employed  to  designate  cases  in  which  similar  clinical  symptoms 
exist,  but  in  which  no  lesions  are  found. 

But,  as  Koch  says,  the  names  pyaemia  and  septicaemia  no  longer  express 
what  was  originally  meant  by  them.  For  pyaemia  does  not  arise,  as  was  for- 
merly supposed,  from  the  entrance  of  pus  into  the  bloodvessels,  nor  is  septi- 
caemia a  putrefaction  of  the  living  blood.  These  have  only  remained  in  use 
as  general  names  for  a  number  of  symptoms,  which  most  probably  belong  to 
a  series  of  different  diseases.  In  this  article  the  word  pyaemia  will  be  used 
as  a  general  term  to  designate  the  entire  group  of  cases. 


Nature  of  Pyemia. 

There  are  three  theories  which  have  been  held  as  to  the  nature  of  pyaemia : — 

I.  That  pus  is  absorbed,  circulates  in  the  blood,  and  acts  as  a  poison; 

II.  That  a  chemical  poison  is  evolved  from  pus  and  the  other  matters  which 
are  found  in  wounds,  and  that  the  system  is  poisoned  by  this ; 

III.  That  microscopic  organisms  are  introduced  into  and  developed  in  the 
wound,  find  their  way  into  the  blood  and  tissues,  and  there  multiply. 

I.  The  Theory  of  Pus  Absorption. — The  idea  that  pus  can  be  absorbed 
and  act  as  a  blood  poison,  is  a  very  old  one,  dating  from  the  times  of  Ambroise 
Pare  (1561)  and  Boerhaave  (1720).  Hunter,  in  1784,  modified  the  prevailing 
views  by  declaring  that  the  pus  was  derived  from  the  interior  of  inflamed 
veins,  and  found  its  way  from  thence  into  the  circulating  blood.  The  idea 
that  the  symptoms  and  lesions  of  pyaemia  were  due  to  the  presence  of  pus  in 
the  blood,  whether  absorbed  from  wounds  or  from  inflamed  veins,  continued 
to  prevail,  based  partly  upon  clinical  observation,  partly  upon  the  results  of 
injections  of  pus  into  the  veins  of  animals,  until  there  appeared,  in  1846  and 
in  subsequent  years,  the  studies  of  Virchow  concerning  thrombosis  and  embo- 
lism. He  showed  that  the  changes  in  the  veins  which  had  been  regarded 
as  due  to  phlebitis,  Averc  caused  by  the  coagulation  of  the  blood,  and  by  sub- 
sequent degenerative  changes  in  the  thrombi  thus  formed ;  that  the  infarc- 
tions and  abscesses  seen  in  the  viscera  were  due  to  emboli  which  had  become 
detached  from  the  softened  thrombi;  that,  as  the  white  blood  globules  and 
pus  globules  were  identical  in  appearance,  they  could  not  be  distinguished; 
and  that  it  was  improbable  that  pus  globules  made  their  way  into  the  blood. 
These  researchej  afforded  a  mechanical  explanation  of  some  of  the  lesions  of 
pyaemia.  But  there  was  still  a  tendency  to  ascribe  to  the  absorption  of  lauda- 
ble pus  a  certain  number  of  the  lesions  and  symptoms.  Sedillot,  Weber, 
Billroth,  ami  others,  have  held  that  laudable,  fresh  pus,  was  capable  of  being 
absorbed,  and  of  producing  a  febrile  movement.  This  opinion  has,  indeed, 
been  controverted,  but  the  doctrine  of  the  absorption  of  laudable  pus  has 
hardly  yet  disappeared  from  pathology. 


II.  Tin:  Chemical  Theory. — Gaspard  (1822),  one  of  the  earliest  investiga- 
tors of  septicaemia,  suggested  that  the  poison  might  be  one  of  the  chemical 
products   of  putrefaction.      This  opinion  was  sustained  during  subsequent 


NATURE   OF   PYJSMIA.  205 

years  by  other  observers.  The  most  thorough  studies  of  the  subject,  how- 
ever, from  this  point  of  view,  are  those  of  Panum  (1855  and  1874).  His 
studies  were  careful  and  systematic,  and  were  carried  on  during  a  number  of 
years.  His  conclusions  are  essentially  as  follows:  "It  is  demonstrated  that 
there  is  in  putrefying  fluids  a  specific,  chemical  substance,  soluble  in  water. 
This  substance,  if  introduced  into  the  blood,  produces  the  peculiar  symptoms 
which  belong  to  what  is  usually  called  putrid  or  septic  infection.  This  sub- 
stance possesses  such  infectious  properties  after  being  completely  freed  from 
all  microscopic  organisms."  Attempts  to  isolate  this  infectious  substance  and 
find  a  definite  chemical  composition  for  it,  have  not  been  successful.  Ililler 
(1876)  also  went  over  the  ground  very  thoroughly,  and  arrived  at  the  con- 
clusion that  there  were  two  putrid  poisons:  A  chemical  poison,  producing 
symptoms  in  proportion  to  its  dose ;  and  a  septic  ferment  of  great  malignity, 
a  malignity  increased  by  successive  inoculations.  Besides  these  views  of  a 
chemical,  putrid  poison,  it  must  not  be  forgotten  that  the  introduction  of  a 
variety  of  substances  into  the  circulation  can  produce  fever.  Blood,  solutions 
of  sulphate  of  ammonium,  even  distilled  water,  can  act  in  this  way.  It  must 
also  be  remembered  that  in  simple  fractures,  where  no  air  or  germs  contained 
in  the  air  can  approach  the  wound,  there  may  be  fever.  In  such  cases  it 
seems  probable  that  the  absorption  of  the  tissues  destroyed  by  the  contusion 
may  be  the  efficient  cause. 

III.  The  Germ  Theory. — This  theory  is  founded  on  Pasteur's  studies  concern- 
ing putrefaction  and  fermentation.  He  has  demonstrated,  to  almost  universal 
satisfaction,  that  putrefaction  and  fermentation  are  due  to  the  presence  and 
growth  of  certain  minute  organisms;  that  unless  these  organisms  are  present, 
fermentation  and  putrefaction  do  not  take  place ;  that  these  organisms  are  in 
suspension  in  the  air,  and  that  it  is  for  this*  reason  that  the  access  of  air  in- 
duces putrefaction.  From  these  facts  came  the  probability  that  the  different 
infectious  diseases  might  be  due  to  analogous  processes;  to  the  introduction 
of  microscopic  organisms  into  the  body,  and  to  their  multiplication  there. 
Septicaemia  and  pyaemia  have  been  especially  studied  from  this  point  of  view. 
Notwithstanding  all  the  work  that  has  been  done,  however,  we  are  still  far 
from  positive  results.  Investigations  have  been  carried  on  in  two  directions: 
(1)  examinations  of  the  blood  and  tissues  in  persons  who  have  died  of  pyaemia 
and  septicaemia ;  and  (2)  the  production  and  study  of  similar  lesions  in 
animals. 

(1)  The  Examination  of  the  Blood  and  Tissues  in  Persons  ivho  have  Died  of 
Pyaemia  and  Septicaemia. — -This  study  is  rendered  singularly  difficult  by  the 
minute  size  of  the  microscopic  organisms,  and  all  attempts  to  distinguish 
these  bodies  by  means  of  staining  or  of  chemical  reagents  have  so  far  proved 
unsatisfactory.  They  are  found  of  two  principal  shapes;  little  rods  of  various 
sizes,  which  may  be  single  or  joined  in  chains;  and  little  globules  which  are 
collected  in  masses,  or  joined  to  form  chains  or  dumb-bells,  or  scattered  singly. 
The  generic  name  for  both  is  bacteria,  but  it  has  become  customary  to  call 
the  rods  bacteria,  and  the  little  round  bodies  microco^-i,  although  other  names 
have  also  been  given  to  them.  The  larger  rods  and  the  clumps  of  micro- 
cocci can  usually  be  made  out,  but  the  smallest  rods  and  the  scattered  micro- 
cocci are  always  uncertain  objects.  It  is  also  still  undecided  whether  the 
micrococci  and  bacteria  are  the  same  organism  in  different  stages  of  develop- 
ment; whether  there  are  a  variety  of  these  organisms,  one  for  each  infectious 
disease ;  whether  any  of  them  are  altogether  harmless.  Observations  differ 
also  as  to  whether  the  rods  or  the  micrococci,  or  either  indifferently,  are  the 
active  agents. 

Birch-IIirschfeld,  examining  the  fluids  from  a  number  of  wounds,  found 


206  PYAEMIA   AND   ALLIED   CONDITIONS. 

that  the  pus  from  healthy  wounds  sometimes  contained  rod  bacteria,  some- 
times no  organisms;  but  that  when  micrococci  were  present,  the  wounds 
were  uniformly  unhealthy.  In  the  blood  of  pyemic  patients,  he  found  some- 
times nothing,  sometimes  micrococci  in  the  plasma  and  in  the  white  blood- 
globules.  He  also  found  that  pus  from  pysemic  patients  was  more  infections 
than  putrefying  fluids,  when  injected  in  animals,  and  that  such  pus  was  less 
infectious  after  it  had  begun  to  putrefy.  He  believes  that  the  micrococci 
rather  than  the  rod  bacteria  produce  pyaemia.  On  the  other  hand,  Ranke 
has  found  micrococci  regularly  present  in  wounds  treated  antiseptically. 
Cheyne  found  that  no  rod  bacteria  were  present  in  the  discharges  from 
wounds  treated  antiseptically,  but  that  micrococci  were  often  present.  He 
regards  the  presence  of  bacteria  as  causing  pyaemia,  while  micrococci,  he 
believes,  are  harmless. 

The  committee  of  the  London  Pathological  Society  found  that  organisms 
were  sometimes  present  in  the  blood,  sometimes  absent.  Rods  were  found 
most  constantly,  but  besides  these,  ovoid  bodies  measuring  from  3  (*■  to  8  /* 
[micro-millimetre  =  -njVa  millimetre];  other  larger  granules,  sometimes  in 
clumps ;  and  dumb-bells.  In  the  organs  and  tissues  after  death,  the  com- 
mittee found,  in  a  large  number  of  cases,  micrococci ;  especially  in  the  thyroid 
gland,  heart,  lungs,  'liver,  kidneys,  suprarenal  capsules,  spleen,  lymphatic 
glands,  and  blood  clot.  They  were  nearly  always  in  bloodvessels  and  usually 
in  capillaries.  Bacteria  were  only  found  in  two  cases,  both  somewhat  doubt- 
ful.    Many  other  observers  have  also  found  micrococci  in  the  tissues. 

The  general  results  of  the  examinations  of  the  human  subject  are  that,  in 
the  wound,  both  rods  and  micrococci  are  found,  but  that  it  is  doubtful 
whether  one  or  the  other,  or  both, are  the  harmful  agents;  in  the  blood,  both 
rods  and  micrococci  are  sometimes  found,  rods  most  frequently ;  in  the  tis- 
sues, micrococci  are  found  frequently,  rods  but  seldom. 

(2)  The  Experiments  on  Animals  have  consisted  chiefly  in  inoculating  animals 
with  pus  from  pyemic  patients;  with  putrefying  fluids  of  different  kinds, 
especially  blood ;  and  with  blood  from  other  animals. 

The  inoculation  of  pus  from  the  wounds  of  pyemic  patients  is  usually  fatal 
to  animals  ;  sometimes  without  any  lesion,  sometimes  with  metastatic  inflam- 
mations (Birch-IIirsehfeld). 

The  inoculation  of  putrefying  blood  or  other  fluids  acts  in  three  ways.  Large 
doses  destroy  the  life  of  the  animal  after  a  short  time.  Small  doses  produce 
no  symptoms,  or  transitory  ones ;  or  after  some  hours  the  animal  becomes  ill, 
emaciates,  gradually  loses  strength,  and  dies.  The  putrefying  fluids  injected, 
always  contained  bacteria,  and  most  observers  hold  that  if  the  bacteria  are  re- 
moved, the  remaining  fluid  is  harmless.  But  Panum  has  shown  that  the 
fluid  may  be  poisonous  after  the  removal  of  the  bacteria;  and  Ililler  has 
shown  that  the  bacteria,  when  isolated  from  the  putrid  fluid,  may  be  harm- 
less. Davaine  has  shown  that,  in  septicemic  animals  inoculated  successively 
one  from  the  other,  the  blood  becomes  constantly  a  more  virulent  poison. 
Burdon  Sanderson  has  shown  that,  if  a  peritonitis  be  first  artificially  pro- 
duced by  some  chemical  irritant,  the  fluid  from  such  a  peritonitis  will  by 
successive  inoculation  become  more  and  more  virulent,  and  will  contain  bac- 
teria. 

There  has  been  considerable  diversity  of  opinion  as  to  the  constancy  of  the 
presence  of  organisms  in  the  blood  of  animals  thus  inoculated.  Koch,  in  his 
experiments  on  mice,  found  in  the  blood  of  those  killed  by  large  injections  of 
putrid  blood,  a  lew  rods  of  different  sizes,  and  micrococci;  but  if  the  animals 
were  inoculated  with  a  very  little  septic  fluid  and  developed  septic  symp- 
toms, then  only  the  small  rods  were  present  in  large  numbers.  Pasteur  has 
endeavored  to  isolate  the  organisms  peculiar  to  pyaemia  by  successive  culti- 


SYMPTOMS   AND   LESIONS   OF   PYEMIA.  207 

vations.  He  has  arrived  at  the  conclusions  that  there  is  a  special  rod-shaped 
form  of  bacteria,  peculiar  to  pyaemia  ;  that  this  organism  does  not  grow  in 
contact  with  the  air,  but  is  killed  by  it  (anaerobie) ;  that  micrococci  are  de- 
veloped from  these  rods,  which  are  not  affected  by  the  air,  and  which  can 
under  favorable  conditions  grow  into  rods ;  that  there  is  another  form  of  rod- 
bacteria  which  produces  local  suppuration. 

There  seems  good  reason  to  believe,  from  all  these  different  experiments, 
that  putrefying  fluids,  when  injected  beneath  the  skin  or  into  the  veins  of 
animals,  produce  serious  symptoms,  or  death.  These  putrefying  fluids  in- 
variably contain  bacteria.  If  the  bacteria  are  removed  by  filtration,  boiling, 
etc.,  the  fluid  is  still  poisonous  (Panum).  If  the  bacteria  removed  by  filtra- 
tion are  injected,  they  are  also  poisonous  ;  but  if  these  bacteria  are  washed 
repeatedly,  they  may  be  innocuous  (Hiller).  On  the  other  hand,  successive 
cultivations  of  a  particular  kind  of  bacteria,  in  indifferent  fluids,  produces  an 
organism  which  is  constantly  poisonous  (Pasteur). 

These  putrefying  fluids  seem  to  act  in  two  ways:  (1)  as  a  direct  and  rapid 
poison ;  (2)  in  small  doses  as  a  slower  poison.  In  the  animals  killed  by  large 
doses,  few  or  no  bacteria  are  found  in  the  blood,  nor  is  their  fresh  blood  poi- 
sonous to  other  animals.  In  the  animals  killed  slowly,  by  small  doses,  bacteria 
are  found  in  the  blood,  and  the  fresh  blood  is  poisonous  to  other  animals.  It 
is  still  uncertain  whether  the  symptoms  and  lesions  produced  in  animals  by 
such  injections  of  putrefying  fluids,  are  identical  with  the  symptoms  and 
lesions  of  pyaemia  in  man. 


Symptoms  and  Lesions  of  Pyaemia. 

It  is  impossible  to  describe  the  symptoms  and  lesions  of  pyaemia,  as  we  can 
those  of  a  definite  disease.  The  best  that  can  be  done  is  to  enumerate  the 
different  conditions  which  are  commonly  spoken  of  under  the  name  of  pyae- 
mia, and  to  describe  the  symptoms  and  lesions  which  belong  to  each  con- 
dition. 

I.  There  are  a  certain  number  of  cases  of  wounds  and  of  injuries,  which  are 
characterized  by  the  presence  of  a  febrile  movement,  without  any  other  symp- 
toms. The  wound  is  healthy,  the  patient's  general  condition  is  good,  the 
febrile  movement  is  of  moderate  intensity,  lasts  a  few  days,  then  disappears, 
and  the  patient  goes  on  to  recovery.  This  symptom  occurs  in  cases  of  wounds 
which  are  left  open,  in  a  certain  number  of  cases  in  which  the  wounds  are 
treated  antiseptieally,  and  in  simple  fractures,  especially  fractures  of  the  thigh 
(Volkmann).  In  these  cases,  there  seems  to  be  no  infection  from  without ;  no 
development  of  any  organism  ;  no  formation  of  a  chemical  poison.  It  seems 
probable  that  the  febrile  movement  is  due  to  the  absorption  of  portions  of 
tissue  which  are  dead,  but  not  putrefying.  In  such  wounds  and  fractures, 
the  injury  is  often  sufficient  to  destroy  the  vitality  of  some  portions  of  tissue. 
These  portions  do  not  putrefy,  but  undergo  necrobiotic  changes.  The  absorp- 
tion of  such  dead  tissues  in  certain  susceptible  persons  may  be  capable  of  pro- 
ducing a  febrile  movement. 

II.  There  are  cases  in, which  in  some  part  of  the  body  a  portion  of  tissue  is 
not  only  dead,  but  undergoing  putrefaction.  While  this  process  of  putrefac- 
tion is  going  on,  the  patient  suffers  from  rigors,  a  febrile  movement,  disturb- 
ance of  the  stomach  and  great  prostration,  and  may  even  die.  But  if  the 
putrefactive  process  is  arrested  in  time,  all  these  symptoms  at  once  disappear, 
and  the  patient  recovers.     The  most  marked  examples  of  such  a  condition 


208  PYEMIA    AND    ALLIED    CONDITIONS. 

are  seen  after  childbirth.  A  woman,  after  a  natural  labor,  is  doing  perfectly 
well,  until  on  the  fourth  day  she  is  seized  with  rigors,  a  febrile  movement, 
and  vomiting.  The  temperature  runs  up  to  10-4°,  there  is  great  prostration, 
the  woman  looks  very  ill.  She  remains  in  this  condition  for  48  hours  ;  then, 
after  repeated  syringing,  a  small  piece  of  putrid  membrane  is  discharged  from 
the  uterus.  Within  half  an  hour  the  temperature  has  fallen  to  the  normal, 
and  the  patient  has  no  other  bad  symptoms.  The  cases  may  be  even  more 
serious  than  this;  J.  Matthews  Duncan  reports  the  following:— 

A.  E.  was  delivered  naturally  of  her  second  child  on  June  8.  Flooding  occurred 
after  the  birth  of  the  child,  and  slight  loss  of  blood  continued  for  seven  days.  Then 
the  lochia  became  fetid.  On  the  eighth  day,  she  had  rigors,  which  were  repeated 
daily.  She  was  brought  into  the  hospital  on  the  tenth  day,  and  was  delirious  that 
night.  On  the  eleventh  day,  she  complained  of  no  pain,  was  pale,  sick,  frequently 
vomiting,  with  diarrhoea,  the  uterus  tender,  breath  sweet,  respiration  44,  pulse  14G, 
temperature  104°,  copious  flow  of  stinking  lochia.  A  piece  of  placenta  was  removed 
from  the  vagina.  Under  the  influence  of  chloroform  the  hand  was  introduced  into  the 
uterus,  and  adherent  placental  masses  were  removed.  The  whole  genital  tract  was 
then  washed  out  with  a  solution  of  carbolic  acid.  That  night  the  delirium  ceased;  the 
pulse  was  100,  the  temperature  101°.     After  this,  the  recovery  was  uninterrupted. 

Similar  symptoms  are  seen  in  some  persons  who  have  received  wounds. 

A  man,  19  years  old,  was  shot  in  the  popliteal  space.  On  the  same  day  the  bullet 
was  extracted,  and  the  wound  dressed  antiseptically.  The  wound  discharged  so  freely 
a  sero-san<niineous  and  sero-purulent  fluid,  that  the  antiseptic  dressings  were  renewed 
on  the  1st,  2d,  4th,  5th,  and  6th  days  after  the  injury.  On  the  2d  day,  the  tem- 
perature was  100°  F.  in  the  evening.  On  the  4th  day,  the  temperature  was  101°  in 
the  evening;  on  the  6th  day,  102°  throughout  the  day.  But,  except  for  the  febrile 
movement,  the  patient  was  feeling  well.  On  the  7th  day,  the  dressing  was  renewed; 
and  it  was  found  that  the  edges  of  the  wound  were  dark-colored  and  sloughing ;  tempe- 
rature 100°-102°.  On  the  8th  day,  the  dressing  was  again  renewed;  the  wound 
was  unhealthy  and  smelt  badly,  temperature  100°  ;  general  condition  of  patient  con- 
tinued good.  On  the  13th  day,  there  was  so  much  bleeding  that  it  was  necessary  to 
lisate  the  popliteal  artery;  this  was  done  antiseptically,  temperature  98°-102°.  On 
the  14th  and  loth  days,  the  dressings  were  changed;  there  was  a  good  deal  of  bad 
smelling  discharge  from  the  wound,  temperature  100°-101°.  On  the  16th  day,  the 
wound  was  foul  and  sloughing,  temperature  101°-103°.  From  the  17th  to  the  25th 
days,  the  patient  had  repented  rigors,  followed  by  sweating,  temperature  98°-102°, 
wound  continued  unhealthy ;  patient  lost  flesh  and  strength  ;  there  was  apparently  a 
thrombus  in  one  of  the  superficial  veins  of  the  leg.  After  the  25th  day,  the  condition 
of  the  wound  improved,  the  temperature  fell;  the  rigors  and  sweating  gradually  ceased. 
By  the  46th  day,  the  wound  had  healed,  and  the  patient  was  well. 

In  this  case,  notwithstanding  antiseptic  dressings,  the  wound  became  un- 
heal thy  and  contained  putrefying  tissue  and  fluids.  While  the  wound 
remained  in  this  condition,  there  was  a  febrile  movement  of  moderate  inten- 
sity, and  a  gradual  loss  of  flesh  and  strength;  the  rigors  and  sweating  may 
have  been  due  to  the  venous  thrombosis.  When  the  wound  became  healthy, 
and  I  lie  putrefying  substances  had  disappeared,  the  symptoms  ceased  and  the 
patient  recovered. 

If  the  amount  of  putrefying  tissue  is  sufficiently  large,  and  if  it  is  not  re- 
moved, the  symptoms  of  poisoning  continue,  and  the  patient  dies, 

A  man,  ?>H  years  old,  who  had  suffered  for  several  years  from  disease  of  the  knee, 
Bubmitted  to  resection  of  that  joint.  On  the  day  after  the  operation,  there  was  some 
fever.  The  wound  was  not  dressed  antiseptically,  a  thin  sanious  fluid  exuded  from  it. 
There  was  no  attempl  al  repair  until  the  7th  day,  when  the  superficial  portions  of  the 
wound  commenced  to  granulate.     The  lever  continued,  the  patient  emaciated,  and  on 


SYMPTOMS   AND   LESIONS    OF   PYJEMIAt  209 

the  9th  clay  he  became  delirious.  On  the  loth  day,  there  were  severe  rigors.  The  fever 
and  delirium  continued,  the  patient  gradually  sank,  and  died  on  the  19th  day  after  the 
operation.  At  the  autopsy  it  was  found  that  the  edges  of  the  wound  were  granulating, 
but  that  its  cavity  was  filled  with  foul  pus.  There  were  no  thrombi  in  the  veins ;  no 
lesions  in  the  viscera. 

In  such  cases  as  these,  it  seems  evident  that  the  cause  of  the  symptoms  is 
the  condition  of  the  wound,  and  this  condition  in  turn  seems  to  be  due  to 
putrefaction.  There  appear  to  be  only  two  probable  explanations  of  the  way 
in  which  the  condition  of  the  wound  can  produce  constitutional  symptoms : 
either  some  morbid  material  is  absorbed  from  the  wound,  and  poisons  the 
system ;  or  the  mere  presence  of  such  an  unhealthy  wound  is  sufficient.  It 
seems  that  if  it  is  a  poison  which  is  absorbed,  this  poison  does  not  multiply 
after  absorption,  for  the  symptoms  only  continue  while  the  wound  remains 
unhealthy,  and  the  severity  of  the  symptoms  is  in  proportion  to  the  amount 
of  putrefying  tissue.  If  the  patient  dies,  no  lesions  are  found  except  the 
unhealthy  wound,  and  perhaps  thrombi  in  some  of  the  veins. 

The  indications  for  treatment  seem  to  be  evident,  to  remove  the  putrefying 
tissues ;  or,  if  this  cannot  be  done,  to  adopt  such  local  treatment  as  will  stop 
the  putrefactive  process. 

III.  There  are  cases  in  which  the  original  wound  is  very  small,  but  in 
which  some  foreign  substance  appears  to  be  introduced  into  the  body  through 
the  wound,  and  to  act  as  a  poison.  The  most  marked  examples  of  such  cases 
are  some  of  the  so-called  dissecting  wounds. 

It  has  long  been  known  that  the  worst  dissecting  wounds  are  those  received 
in  examining  a  body  in  which  decomposition  has  not  commenced,  and  that 
the  bodies  of  those  dying  with  acute  peritonitis  are  especially  dangerous.  It 
is  also  known  that  a  small  puncture  or  scratch  is  sufficient  for  the  infection. 

The  symptoms  do  not  appear  until  several  hours  after  the  infliction  of  the 
wound.  Then  there  are  rigors,  a  febrile  movement,  and  marked  general 
prostration.  There  will  be  a  little  redness  about  the  wound,  and  inflamed 
lymphatics  extending  up  the  arm.  A  general,  unhealthy  inflammation  of  the 
arm  follows,  the  patient  passes  into  a  typhoid  condition,  and  dies  in  from  ten 
days  to  three  weeks. 

Cases  similar  to  these  are  observed,  in  which  we  are  unable  to  discover  the 
source  of  the  infection  : — 

A  man,  twenty-six  years  old,  a  porter  by  occupation,  received  a  slight  lacerated 
wound  of  the  left  forefinger  nine  days  before  his  death.  It  was  not  known  in  exactly 
what  way  the  injury  had  been  received.  Six  days  before  death,  the  left  hand,  fore- 
arm and  arm  became  swollen,  as  did  also  the  axillary  glands  ;  there  were  fever  and 
marked  prostration.  The  fever  continued,  the  patient  vomited  constantly,  passed  into 
a  typhoid  condition,  and  died.  At  the  autopsy  there  was  found  diffuse,  unhealthy  in- 
flammation of  the  connective  tissue  of  the  hand  and  arm,  and  of  the  axillary  glands. 
There  were  red  infarctions  in  the  right  lung,  and  in  one  of  the  kidneys. 

Similar  cases  are  also  seen  after  operations  :— 

A  child,  seven  years  old,  had  the  knee  resected  for  the  relief  of  a  chronic  inflamma- 
tion. The  wound  was  dressed  antiseptically,  and  there  was  no  odor  in  the  discharge  at 
any  time.  The  patient  began  to  vomit  on  the  day  after  the  operation,  and  continued 
to  do  so.  The  temperature  was  never  above  101°  ;  and  fell  to  96.2°  before  death.  The 
leg  became  swollen ;  the  patient  became  cold,  cyanotic,  and  pulseless,  and  died  on  the 
fifth  day  after  the  operation.  There  were  no  lesions  except  a  slight  swelling  of  the 
liver,  spleen,  and  kidneys.1 

1  Report  of  the  Committee  of  the  London  Pathological  Society.     Transactions,  vol.  xxx.  1879. 
VOL.  I. — 14 


210  PY.EMIA   AND   ALLIED   CONDITIONS. 

In  such  cases  as  these,  it  seems  evident  that  the  cause  of  the  general  infec- 
tion does  not  reside  in  the  wound,  but  is  received  into  the  body  through  the 
wound.  It  also  seems  probable  that  the  poison  thus  taken  into  the  system, 
is  capable  of  multiplication  after  being  absorbed  ;  for  there  is  no  proportion 
between  the  symptoms  and  the  amount  of  poison  which  can  have  been  ab- 
sorbed by  the  wound.  There  is  only  the  single  inoculation,  but  the  S3nnp- 
toms  continue,  and  become  more  marked.  In  most  of  these  cases,  the  symp- 
toms do  not  immediately  follow  the  inoculation,  but  there  is  a  period  of 
several  hours  which  intervenes  between  the  receipt  of  the  injury  and  the  de- 
velopment of  the  sj'mptoms.  It  seems  probable,  therefore,  that  the  poison  is 
an  organism,  capable  of  multiplying  itself  in  the  body. 

After  death  from  such  a  cause,  there  are  no  characteristic  lesions  ;  but 
there  may  be  early  decomposition,  staining  of  the  endocardium  by  the  color- 
ing matter  of  the  blood,  a  large  soft  spleen,  and  degeneration  of  the  cells  of 
the  liver  and  kidneys. 

IY.  There  is  a  very  large  class  of  cases  which  it  is  difficult  to  classify. 
They  are  the  ordinary  hospital  cases  of  compound  fractures  and  surgical 
wounds.  It  is  difficult  to  tell  whether  a  poison  derived  from  without  and 
taken  up  by  the  wound,  or  a  poison  developed  in  the  wound,  or  the  forma- 
tion of  thrombi  in  the  veins,  is  to  be  looked  upon  as  the  efficient  cause  ;  or 
whether  different  causes  may  combine  in  the  same  case.  The  symptoms  are 
familiar  to  every  surgeon.  Within  a  few  days,  sometimes  not  until  after  two 
or  three  weeks,  from  the  time  the  patient  received  the  original  injury,  he 
develops  a  febrile  movement,  rigors,  sweating,  great  prostration,  rapid  ema- 
ciation, vomiting,  diarrhoea,  delirium,  and  jaundice.  The  tongue  becomes 
dry  and  brown,  the  breath  has  a  peculiar  sweetish  odor,  the  pulse  is  rapid 
and  feeble,  and  the  patient  dies  exhausted.  [The  irregularity  and  absence  of 
periodicity  in  the  chills,  and  the  great  variations  in  temperature,  which 
range  over  10°  or  11°  F.,  may  be  looked  upon  as  of  diagnostic  value.] 

After  the  death  of  these  patients,  there  is  a  considerable  variety  in  the  post- 
mortem appearances : — 

(1)  There  are  cases  in  which  there  are  no  recognizable  lesions. 

(2)  There  are  cases  characterized  by  early  decomposition ;  post-mortem 
staining  of  the  tissues;  congestion  of  the  lungs,  stomach,  intestines,  and  kid- 
neys ;  extravasation  of  blood  in  the  serous  membranes  ;  swelling  of  the  solitary 
and  agminated  glands  in  the  small  intestine  ;  swelling  of  the  spleen ;  degenera- 
tive changes  in  the  cells  of  the  liver  and  kidneys. 

(3)  There  are  cases  in  which  we  find  localized  inflammations.  The  parts 
most  frequently  inflamed  are  the  joints,  the  connective  tissue  around  the  joints, 
the  pleurae,  the  pericardium,  the  peritoneum,  the  pia  mater,  and  the  connective 
1  issue  in  different  parts  of  the  body.  These  local  inflammations  are  of  a  puru- 
lent character,  except  in  the  serous  membranes,  where  the  principal  inflam- 
matory product  may  be  flbrine. 

(4)  There  are  eases  in  which  the  veins  in  the  neighborhood  of  the  wound 
contain  softened  and  puriform  thrombi;  there  are  no  infarctions  in  the 
viscera,  but  in  some  eases  local  inflammations  of  the  joints  and  serous  mem- 
branes. 

(5)  There  arc  cases  in  which  the  veins  contain  thrombi;  there  are  infarc- 
tions and  abscesses  in  the  viscera;  and  local  inflammations  of  the  joints  and 
serous  membranes  are  also  present,  or  may  be  absent.  The  thrombi  are  formed 
regularly  in  the  veins  in  the  neighborhood  of  the  wound;  sometimes,  how- 
ever, they  are  found  in  veins  at  a  distance  from  the  wound;  sometimes, 
although  the  infarctions  and  abscesses  ;ire  present,  the  thrombi  cannot  be  dis- 
covered.    The  veins  may  be  distended  by  the  thrombi,  or  may  only  contain 


aaaJ  /qjcwajoaaA    AkcLfyca. 


TREATMENT    OF   PYAEMIA.  211 

small  coagula.  The  thrombi  look  like  fibrine  which  has  been  coagulated 
some  time,  of  a  coarse,  granular  texture,  whitish,  reddish,  or  mottled  ;  or  they 
are  partly  softened  into  a  reddish,  sticky  fluid  ;  or  they  are  softened  into  a 
yellowish,  puriform  fluid  mixed  with  micrococci;  or  they  putrefy  with  the 
growth  of  bacteria  and  the  evolution  of  gases.  Weigert  has  described  small 
thrombi,  adherent  to  the  walls  of  the  veins,  composed  of  bacteria  alone. 
There  are  usually  inflammatory  changes  in  the  wall  of  the  vein  which  con- 
tains the  thrombus,  especially  if  the  thrombus  degenerates  and  softens. 

Tortious  of  the  softened  thrombi  may  become  detached,  be  carried  into  the 
circulation,  and  finally  become  lodged  in  some  artery  or  .capillary.  After 
becoming  lodged  in  this  way,  such  portions  of  thrombi  may  act  only  mechani- 
cally, by  obstructing  the  circulation  of  the  blood ;  or  may  also  act  as  local 
irritants,  setting  up  a  zone  of  inflammation  about  them.  It  is  the  softened, 
puriform,  bacteritic  thrombi  from  which  such  infectious  emboli  are  derived. 
The  mechanical  emboli  produce  the  so-called  infarctions,  especially  in  the  lungs 
the  spleen,  and  the  kidneys.  These  infarctions  are  small,  wedge-shaped  por- 
tions of  the  affected  viscus,  usually  situated  near  the  surface,  with  the  large 
end  of  the  wedge  outwards.  They  are  of  a  dark  red  color,  or  decolorized  at 
the  centre,  or  white,  or  softened  and  broken  down.  The  red  infarctions  are 
produced  by  a  congestion  of  the  bloodvessels,  and  an  infiltration  of  blood 
into  the  tissue.  This  congestion  and  infiltration  are  due  to  a  regurgitation  of 
venous  blood,  and  a  change  in  the  walls  of  the  vessels  (Cohnheim);  or  to  a 
supply  of  blood  from  collateral  vessels  which  is  not  carried  off  by  the  veins 
(Litten).  The  white  infarctions  are  portions  of  tissue  which  are  undergoing 
slow,  necrotic  changes  as  a  result  of  their  loss  of  blood  supply  (Litten). 

The  infectious  emboli  produce  abscesses  of  various  sizes.  Such  abscesses  are 
found  most  frequently  in  the  lungs  and  liver,  but  they  may  also  occur  in  the 
brain,  heart,  and  other  viscera.  The  abscesses  are  of  irregular,  globular  shape, 
and  may  be  situated  in  any  part  of  a  viscus. 

The  portions  of  thrombi  in  the  veins,  which  become  detached,  must  of 
course  pass  into  the  right  heart,  and  from  thence  into  the  lungs.  It  has  always 
been  a  question  how  such  fragments  of  thrombi  can  find  their  way  into  the 
aortic  system  of  arteries,  especially  in  those  cases  in  which  no  infarctions  or 
abscesses  are  found  in  the  lungs.  The  ordinary  explanation  is  that  some  of 
the  portions  of  thrombi  are  small  enough  to  pass  through  the  vessels  of 
the  lungs,  and  so  find  their  way  into  the  left  heart;  and  that  in  other  cases 
secondary  thrombi  are  formed  in  the  lungs,  from  which  fragments  are  de- 
tached and  pass  into  the  left  heart.  It  is  also  possible  that  small  agu'rt'Lra- 
tions  of  bacteria  may  find  their  way  from  the  veins,  through  the  lungs,  into 
the  left  heart. 

It  is  the  rule  that  abscesses  in  different  parts  of  the  body  are  found  in  those 
cases  in  which  no  thrombi  can  be  demonstrated  in  the  veins,  and  that  infarc- 
tions in  the  lungs  alone,  are  found  in  those  cases  in  which  thrombi  can  be 
demonstrated  in  the  veins.  Bacteria  and  micrococci  are  usually  present  in 
the  wound,  in  the  puriform  thrombi,  and  in  the  abscesses.  In  the  blood, 
during  life,  they  seem  to  be  sometimes  present,  sometimes  absent. 


Treatment  of  Pyemia. 

There  seems  to  be  no  question  that  the  only  successful  plan  of  treating 
these  cases  of  pyaemia  is  a  preventive  one.  When  the  symptoms  are  once 
fairly  developed,  treatment  is  of  no  avail.  It  is  indeed  possible  for  patients 
to  recover  from  the  disease,  but  this  seems  to  be  due  to  their  natural  powers 
of  resistance,  rather  than  to  any  treatment. 


212  PYAEMIA   AND   ALLIED    CONDITIONS. 

[The  editor  feels  bound  to  say  that  this  view  appears  to  him  unduly  fatal- 
istic. While  cases  of  acute  pyaemia  terminate  unfavorably  under  any  mode 
of  treatment,  and  while  the  resisting  power  of  the  patient  is  no  doubt  of 
prime  importance  in  all  cases  which  end  in  recovery,  yet  something  may  be 
done  by  treatment  in  subacute  and  chronic  cases,  to  avert  the  fatal  issue.  The 
hygienic  condition  of  the  patient  should,  if  possible,  be  improved,  and  great 
attention  should  be  given  to  careful  nursing  and  systematic  feeding,  very 
free  stimulation  should  be  employed — half  an  ounce  or  an  ounce  of  brandy 
may  be  given  every  hour,  or  an  equivalent  quantity  of  wine — and  the  oil  of 
turpentine  and  carbonate  of  ammonium  may  also  be  administered  with  advan- 
tage. But  the  most  valuable  single  remedy  is  quinia,  which  may  be  given  in 
large  doses— from  one  to  five  grains  every  hour — and  may  be  suitably  com- 
bined with  small  quantities  of  digitalis  and  opium.] 

It  is  a  just  claim  of  modern  surgery  that  these  forms  of  pyaemia  can  be 
in  great  measure  prevented,  and  the  mortality  after  injuries  and  operations 
thus  greatly  diminished.  The  success  attained  in  preventing  these  forms  of 
pyaemia  seems  to  depend  on  two  causes:  (1)  The  steady  improvement  which 
has  been  taking  place  in  the  methods  of  operating,  in  the  general  manage- 
ment of  the  patients,  and  in  the  hygiene  of  hospitals;  and  (2)  The  use  of 
carbolic  acid  as  a  local  application  to  wounds. 

The  first  cause  has  been  a  progressive  one,  and  has  been  due  to  the  efforts 
of  many  surgeons.  Sir  James  Paget  estimates  that  during  his  surgical  prac- 
tice of  30  years,  the  mortality  after  surgical  operations  has  diminished  from 
15  per  cent,  to  less  than  5  per  cent.,  simply  from  these  causes. 

The  use  of  carbolic  acid  as  a  local  application  to  wounds  is  almost  entirely 
due  to  the  teachings  of  Mr.  Lister.  This  method  of  dressing,  however,  was 
adopted  by  Mr.  Lister  as  a  result  of  a  certain  theory  concerning  the  causes  of 
pyaemia.  This  theory  is  based  on  three  hypotheses :  (1)  The  local  inflam- 
matory processes  and  the  general  febrile  disturbances  which  follow  wounds 
are  due  to  putrefaction  of  the  discharges  of  those  wounds.  (2)  This  putre- 
faction of  the  discharge  is  brought  about  by  the  growth  of  organisms.  (3) 
These  organisms  gain  access  to  the  wounds  from  the  air.  The  object  of  treat- 
ment, therefore,  is  to  destroy  any  organisms  already  existing  in  a  wound,  and 
to  prevent  organisms  from  the  air  entering  a  wound  during  or  after  an  opera- 
tion. To  accomplish  these  results,  Mr.  Lister  has  devised  a  system  of  dressing 
based  on  the  use  of  carbolic  acid.  This  system,  as  described  by  Mr.  MacCor- 
mac, is, when  thoroughly  carried  out,  practised  as  follows: — 

If  an  operation  is  to  be  performed,  the  adjacent  surface  must  be  shaved,  and  then 
thoroughly  washed  with  a  five  per  cent,  solution  of  carbolic  acid.  The  actual  steps  of 
the  operation  are  conducted  in  a  carbolized  atmosphere,  produced  by  a  jet  of  steam 
mingled  with  a  five  per  cent,  solution  of  the  acid.  The  sponges  employed,  the  hands 
of  the  operator  and  those  of  his  assistants,  are  thoroughly  purified  in  a  five  per  cent, 
solution,  previous  to  the  operation,  and  again  and  again  during  its  progress.  The  in- 
struments arc  kept  ready  in  a  three  per  cent,  solution,  which  may  also  be  used  for 
washing  the  wound  and  the  sponges.  All  bleeding  points  must  be  carefully  secured 
either  by  torsion,  carbolized  gut,  or  carbolized  silk,  the  ends  of  the  ligatures  being  cut 
short.  The  sutures  should  be  both  deep  and  superficial;  the  former  of  wire,  the  latter 
of  catgut.  The  entire  surface  of  the  wound  should  be  brought  into  apposition.  Drain- 
age tubes  should  be  inserted,  in  order  that  bloody  serum  may  escape  externally.  They 
should  be  removed  as  soon  as  their  function  is  at  an  end.  A  sufficient  number  of  tubes 
having  been  inserted,  the  projecting  portions  are  cut  off  level  with  the  surface,  and  a 
layer  of  protective  silk  applied  to  the  wound.  Over  this  are  placed  several  layers  of 
carbolized  gauze,  wrung  as  dry  as  possible  out  of  a  two  and  a  half  per  cent,  solution  of 
carbolic  acid,  and  fastened  to  the  surface  with  a  carbolized  bandage.  Over  this  is  ap- 
plied an  eight-fold  layer  of  dry  gauze,  a  piece  of  mackintosh  being  interposed  between 
the  last  layers  of  the  gauze.      In  all  cases  the  first  dressing  is  the  most  important. 


PROLONGED  SUPPURATION.  213 

Attempts  to  replace  carbolic  acid  by  any  of  the  other  germicides  have  not 
been  successful. 

The  success  of  this  plan  of  treatment  has  been  very  great.  Hospitals,  espe- 
cially in  Germany,  which  were  previously  mere  pest-houses,  now  give  good 
surgical  statistics.  Its  disadvantages  are  the  trouble,  time,  and  expense  in- 
volved in  carrying  out  the  full  system  of  dressings,  and  the  possibility  of 
poisoning  the  patient  by  too  much  carbolic  acid.  For  this  reason,  many  sur- 
geons have  discarded  the  complete  Listerian  system  of  dressing,  and  use  car- 
bolic acid  as  a  local  application  in  various  ways. 

Perhaps  the  question  of  antiseptic  dressings  may  be  best  summed  up  in  the 
words  of  Sir  James  Paget : — 

"  I  believe  that,  in  its  complete  (Listerian)  form,  we  can  nearly  neutralize  the  evil 
inflnences  of  unhealthy  hospitals  and  other  like  sources  of  those  infectious  diseases  from 
which  arise  the  largest  portions  of  mortalities  after  operations. 

"That  it  has  not  yet  reduced  the  death-rate  to  a  lower  level  than  can  be  attained  by 
good  sanitary  arrangements,  good  nursing,  strict  care  and  cleanliness,  quietude,  and 
simple  dressing. 

"  That  recoveries  after  operations  are  quicker  and  more  free  from  fever  and  other 
constitutional  disturbances,  when  antiseptics  are  used,  than  when  they  are  not  used. 

"  That  in  certain  groups  of  cases,  operations  may  be  safely  done  with  antiseptics  which, 
without  them,  would  be  very  hazardous." 


Prolonged  Suppuration. 

There  are  cases  of  prolonged  suppuration  which  are  usually  classed  with 
pyfemia.  There  is  first  a  wound,  or  a  bruise,  or  an  idiopathic,  suppurative 
inflammation.  This  original  focus  of  inflammation  is  of  a  purulent  character, 
and  shows  no  disposition  to  heal.  After  a  time,  successive  abscesses  are 
formed,  without  visible  cause,  in  the  connective  tissue  in  different  parts. 
These  new  abscesses  all  show  the  same  disposition,  to  continue  to  suppurate 
and  not  to  heal.  The  patient  loses  flesh  and  strength;  there  is  a  febrile 
movement;  bronchitis  or  broncho-pneumonia  may  be  developed,  and  the 
patient  finally  dies  in  a  condition  of  extreme  emaciation.  After  death,  ab- 
scesses are  found  in  different  parte  of  the  .  body,  but  not  in  the  viscera.  In- 
farctions and  thrombi  do  not  belong  to  this  condition.  The  lungs  show  the 
lesions  of  bronchitis  and  broncho-pneumonia.  The  liver,  spleen,  and  kidneys 
are  often  waxy. 

A  man,  twenty  years  old,  was  admitted  to  the  Roosevelt  Hospital,  February  18,  1880. 
Five  months  before  his  admission,  his  right  testicle  had  become  swollen  and  painful. 
This  epididymitis  had  come  on  one  month  after  sexual  intercourse,  but  had  not  been 
preceded  or  accompanied  by  gonorrhoea.  On  February  15,  he  had  begun  to  have  pain, 
tenderness,  and  redness,  along  the  femoral  vessels  on  the  left  side,  with  nausea,  vomit- 
ing, fever,  and  delirium,  but  no  rigors.  On  February  18,  the  right  epididymis  was 
swollen  and  tender ;  the  lymphatic  glands  in  the  left  groin  were  swollen  and  tender ; 
there  was  an  erythematous  blush  over  the  anterior  surface  of  the  left  thigh ;  there  was 
tenderness,  but  no  induration,  along  the  course  of  the  left  femoral  vessels ;  there  was 
fever.  By  February  27,  the  lymphatic  glands  in  the  left  groin  had  suppurated  ;  the 
abscess  was  opened,  but  it  was  found  that  the  pus  had  burrowed  down  the  anterior  sur- 
face of  the  thigh.  On  March  24,  an  abscess  in  the  right  epididymis  was  opened.  By 
April  4  an^  abscess  had  formed  in  the  right  inguinal  region,  and  by  April  23,  one  above 
the  spine  of  the  scapula.  On  April  29,  an  abscess  had  formed  above  the  right  clavicle, 
and  on  June  5  the  patient  died. 

At  the  autopsy,  the  abscesses  were  found  as  mentioned,  but  no  thrombosis  of  any 
veins.  There  was  purulent  broncho-pneumonia,  and  commencing  waxy  infiltration  of 
the  liver,  spleen,  and  kidneys. 


214  PYEMIA   AND   ALLIED   CONDITIONS. 


Spontaneous  Pyaemia. 

Under  this  name  we  include  a  group  of  obscure  cases,  which  resemble  ordi- 
nary pyaemia  in  their  symptoms  and  lesions,  but  are  of  obscure  etiology.  They 
do  not  begin  with  a  wound,  or  bruise,  or  abscess. 

An  individual,  without  known  cause,  will  be  seized  with  rigors  followed 
by  a  febrile  movement,  and  marked  prostration.  There  may  be  vomiting,  or 
diarrhoea,  or  cough.  Sometimes  ecchymoses  or  pustules  appear  in  the  skin. 
Usually  headache  and  delirium  are  present.  The  patients  die  in  a  typhoid 
condition.  At  the  autopsy,  lesions  are  found  like  those  of  pyaemia :  abscesses 
and  infarctions  in  the  lungs  and  kidneys ;  suppurative  inflammations  of  the 
joints  and  connective  tissue. 

A  girl,  ten  years  old,  after  playing  in  the  snow,  was  seized  with  rigors,  followed  by  a 
febrile  movement,  and  with  pains  all  over  the  body.  The  fever  continued  ;  she  became 
delirious  ;  the  pain  was  most  intense  in  the  right  hip.  She  passed  into  a  typhoid  condi- 
tion and  died  on  the  ninth  day.  At  the  autopsy,  the  right  pleural  cavity  was  found 
half  full  of  purulent  serum,  the  left  pleura  coated  with  fibrine,  and  both  lungs  studded 
with  hemorrhagic  infarctions.  The  kidneys  contained  infarctions  ;  there  was  a  small 
abscess  under  the  scalp ;  both  hip-joints  and  one  sterno-clavicular  articulation  con- 
tained pus. 

A  man,  forty-seven  years  old,  of  intemperate  habits,  was  attacked  twenty-six  days 
before  his  death  with  headache,  loss  of  appetite,  and  a  general  tenderness  over  the 
muscles  ;  but  was  not  confined  to  bed.  Eleven  days  before  his  death,  rigors,  a  febrile 
movement,  diarrhoea,  and  pain  in  the  chest  came  on.  He  was  noAv  so  ill  that  he  was 
confined  to  bed.  Eight  days  before  death  he  became  delirious,  and  continued  so.  After 
this  the  temperature  was  from  103°-107°  F.,  the  breathing  from  42-48,  the  pulse  from 
112-120.  There  were  no  physical  signs  except  a  double  aortic  and  a  mitral  systolic 
murmur.  There  were  a  few  red  spots  in  the  skin,  on  the  upper  part  of  the  abdomen. 
The  patient  passed  into  a  typhoid  condition,  and  died. 

An  autopsy  was  made  three  hours  after  death.  The  brain  was  not  examined.  The 
heart  showed  the  aortic  and  mitral  valves  to  be  thickened  and  insufficient,  but  not 
roughened  ;  the  left  ventricle  was  hypertrophied  ;  the  heart  cavities  were  empty.  The 
larynx  and  pharynx  were  normal.  The  lower  two-thirds  of  the  trachea,  and  the  larger 
bronchi,  were  congested;  their  mucous  membrane  was  coated  with  a  layer  of  tenacious 
muco-pus.  The  small  bronchi  were  full  of  pus.  The  upper  lobes  of  the  lungs  were 
inflated  and  dry,  the  lower  lobes  wrere  congested.  The  liver  appeared  normal.  The 
spleen  was  large  and  soft.  The  stomach  and  intestines  were  normal.  The  kidneys 
were  large ;  in  the  cortex  were  numerous  small  white  foci,  surrounded  by  red  zones. 
These  white  foci  were  formed  of  pus  ;  the  glomeruli  in  the  foci  contained  colonies  of 
micrococci.     The  bladder  was  normal. 

[The  reader  may  consult  with  advantage  papers  by  Dr.  Samuel  Wilks,  on  "  Pyaemia"  and 
"Arterial  pyaemia,"  in  Guy's  Hospital  Reports,  3d  s.,  vols.  vii.  and  xv.] 


HYDROPHOBIA  AND  RABIES;  GLANDERS; 
MALIGNANT  PUSTULE. 


BY 

WILLIAM  S.  FORBES,  M.D., 

DEMONSTRATOR  OF  ANATOMY  IN  THE  JEFFERSON  MEDICAL  COLLEGE  ;    SENIOR  SURGEON  TO  Till 
EPISCOPAL  HOSPITAL,  PHILADELPHIA. 


Hydrophobia  and  Rabies. 

Hydrophobia  is  a  general  malady  which  manifests  itself  chiefly  through 
disturbances  of  the  nervous  system,  of  an  intensely  distressing  character. 
The  word  hydrophobia  (as^p  water  and  $6/30$  fear)  signifies  dread  of  water,  a 
name  suggested  by  the  inability  to  swallow  liquids,  which  forms  one  of  the 
most  prominent  and  marked  features  of  the  disease  as  it  exists  in  man.  In 
consequence  of  the  occasional  absence  of  this  striking  symptom,  and  of  its 
occasional  presence  in  other  diseases,  the  name  has  been  objected  to,  and  the 
word  rabies,  which  is  the  term  applied  to  the  corresponding  affection  met  with 
in  the  lower  animals,  has  been  sometimes  substituted  instead.  It  may  be 
well,  however,  to  retain  the  name  hydrophobia  at  present,  as  it  is  the  one  by 
which  the  disease  is  most  widely  known. 

Cause  of  Hydrophobia. — The  primary  or  exciting  cause  of  hydrophobia 
may  be  said  to  be  the  inoculation  of  the  body  with  a  poison  of  a  specific  cha- 
racter, which  is  generated  or  at  least  contained  in  the  salivary  fluids  or  secre- 
tions from  the  buccal  and  faucial  mucous  membranes  of  an  animal  which  is 
affected  with  rabies,  the  virus  being  introduced  upon  the  animal's  teeth,  or 
possibly  by  its  lips  or  tongue.  It  is  not  necessary  that  there  should  be  an 
actual  bite,  but  an  abraded  surface  must  exist,  in  order  that  inoculation  shall 
be  effected.  Hydrophobia  is  apparently  produced  by  the  action  of  this  spe- 
cific poison  upon  the  respiratory  centres  of  the  nervous  system,  producing  a 
morbid  irritability  of  the  medulla  oblongata,  and  of  the  eighth  pair  of  nerves 
of  Willis's  classification. 

Rabies  originates  in  certain  animals,  such  as  the  dog,  the  wolf,  the  fox,  the 
skunk,  the  jackall,  the  cat,  and  the  badger.  The  disease  does  not  originate 
in  man,  and  it  is  not  sure  that  it  can  be  communicated  from  one  human  being 
to  another.  But  animals  in  whom  the  virus  does  not  originate,  are  yet  sus- 
ceptible to  hydrophobia,  and  all  are  probably  capable  of  transmitting  it  when 
under  its  influence.  Magendie  inoculated  two  dogs  with  the  saliva  of  a  man 
suffering  from  hydrophobia  ;  one  of  the  dogs  became  mad  and  bit  two  others, 
one  of  which  also  became  mad  and  died.  The  malady  has  been  provoked  in 
dogs  by  inoculating  them  with  the  saliva  of  rabid  horses  and  asses,  and  cases 
have  been  reported  of  human  beings  having  acquired  hydrophobia  from  the 
bites  of  rabid  horses  and  pigs.     Rabbits  and  similar  animals,  as  well  as  fowls, 

(215) 


216  HYDROPHOBIA — GLANDERS — MALIGNANT   PUSTULE. 

soon  die  from  inoculation  of  this  poison,  without  manifesting  the  ordinary 
symptoms  of  rabies. 

It  is  well  known  that  many  persons  bitten  by  rabid  animals  do  not  con- 
tract hydrophobia,  the  morbid  matter  being  no  doubt  wiped  off  as  the  teeth 
penetrate  the  clothes.  Hence  the  wounds  inflicted  by  rabid  wolves  are  much 
more  dangerous  than  those  received  from  rabid  dogs ;  the  difference  being 
apparently  due  to  the  fact  that  wolves  generally  bite  the  exposed  parts  of  the 
body,  such  as  the  face,  neck,  and  hands,  whereas  dogs  usually  seize  with  their 
teeth  those  parts  that  are  covered.  Sir  Thomas  Watson  writes  that  of  114 
persons  bitten  by  rabid  wolves,  67  died  of  hydrophobia. 

Bouley  gives  the  following  summary  of  facts,  collected  from  the  report 
made  to  the  Consulting  Committee  of  Public  Hygiene,  France : — 

(1)  In  49  departments  wherein  cases  of  rabies  were  reported  by  108  communications, 
320  persons  were  bitten  by  rabid  animals.  This  figure  is  enormous,  but  must  be  re- 
garded nevertheless  as  far  below  the  truth — for  there  are  departments  where  the  disease 
is  common,  from  which  no  reports  were  obtained. 

(2)  Out  of  320  cases  of  persons  bitten,  the  bites  caused  hydrophobia  in  129,  or  a 
proportion  of  about  forty  per  cent. 

(3)  Out  of  320  cases  of  persons  bitten,  the  wounds  were  not  followed  by  the  disease 
in  123  known  and  specified  cases.  The  established  rate  of  exemption  would,  therefore, 
seem  to  be  about  38  per  cent. 

(4)  Among  the  320  bitten  persons,  206  were  males  and  81  females,  while  in  33  cases 
the  sex  was  not  mentioned.  With  reference  to  the  distribution  of  cases  throughout  the 
year,  the  author  mentions  the  following  facts : — 

During  the  three  spring  months,  March,  April,  and  May,  89  cases  occurred ;  during 
the  summer  months,  June,  July,  and  August,  74  cases  ;  during  the  autumn  months, 
September,  October,  and  November,  64  cases ;  and  during  the  winter  months,  Decem- 
ber, January,  and  February,  75  cases.  This  leads  to  the  conclusion,  that  there  is  no 
great  difference  in  the  number  of  cases  between  the  seasons ;  that  the  danger  from  mad 
dogs  in  the  winter  season  is  about  the  same  as  in  the  heat  of  summer  ;  and  that  in  the 
spring  cases  are  most  frequent,  and  in  the  autumn  least  frequent.  The  popular  opinion, 
which  regards  winter  as  free  from  the  curse  of  hydrophobia,  and  which  indicates  that 
the  disease  exists  in  summer  more  than  at  any  other  season,  has  no  foundation  in  fact. 

This  brings  us  to  a  conclusion  of  great  importance,  namely,  that  as  far  as  sanitary 
measures,  and  the  protection  of  the  people  are  concerned,  we  should,  at  all  times  and 
in  all  seasons,  be  equally  on  our  guard,  and  should  take  efficient  measures  of  protection 
against  dogs.  Hydrophobia  is  not  peculiar  to  any  age — it  prevails  in  all  countries  and 
in  all  climates.  It  is  possible  that  idiosyncrasy  may  exert  an  important  influence  in 
preventing  the  effects  of  the  poison.  It  is  well  known  that  this  is  true  of  other  zymo- 
tic poisons. 

This  influence  of  idiosyncrasy  may  be  illustrated  by  the  experience  of  Dr. 
I  [ertnich,  of  Berlin,  who  inoculated  fifty  dogs  with  saliva  taken  from  another 
dog  affected  with  rabies,  and  not  one  in  five  was  affected. 

Rabies  in  the  Dog. — The  disease  as  it  affects  the  dog,  has  been  well  de- 
scribed by  Mr.  Youatt,  and,  as  his  description  has  become  classical,  I  make 

the  following  extracts  : — 

In  the  greater  number  of  cases  there  are  sullenness,  fidgetiness,  and  continual  shift- 
ing of  posture.  When  I  have  had  opportunity  I  have  generally  found  these  circum- 
stances in  succession.  For  several  successive  hours  perhaps  he  retreats  to  his  basket  or 
his  bed.  He  shows  no  disposition  to  bite,  and  he  answers  the  calls  upon  him  laggardly. 
He  is  curled  up,  and  his  lace  is  buried  between  his  paws  and  his  breast.  At  length  he 
begins  to  be  ligdety.  lie  searches  out  new  resting-places,  but  he  very  soon  changes 
them  for  others.  He  takes  again  to  his  own  bed  ;  but  he  is  continually  shifting  his 
posture.  He  begins  to  gaze  strangely  about  him  as  he  lies  on  his  bed.  His  counte- 
nance  is  clouded  and  Buspicious;  he  comes  to  one  and  another  of  the  family,  and  he 


INCUBATION   OF   HYDROPHOBIA.  217 

fixes  on  them  a  steadfast  gaze,  as  if  he  would  read  their  very  thoughts.  "  I  feel  strangely 
ill,"  he  seems  to  say  :  "  have  you  anything  to  do  with  it?  or  you  ?  or  you  ?"  Has  not 
a  dog  mind  enough  for  this  ?     If  we  have  observed  a  rabid  dog,  at  the  commencement 

of  the  disease,  we  have  seen  this  to  the  very  life 

The  disease  manifests  itself  under  two  forms  :  the  furious  form,  characterized  by 
augmented  activity  of  the  sensorial  and  locomotive  systems,  a  disposition  to  bite,  and  a 
continued  peculiar  bark.  The  animal  becomes  altered  in  habits  and  disposition  ;  has 
an  inclination  to  lick  or  carry  inedible  substances ;  is  restless  and  snaps  in  the  air,  but 
is  still  obedient  and  attached.  Soon  there  are  loss  of  appetite  and  the  presence  of 
thirst,  the  mouth  and  tongue  swollen  ;  the  eyes  red,  dull,  and  half  closed  ;  the  skin  of 
the  forehead  wrinkled  ;  the  coat  rough  and  staring  ;  the  gait  unsteady  and  staggering  ; 
there  is  a  periodic  disposition  to  bite  ;  the  animal  in  approaching  is  often  quiet  and 
friendly,  and  then  snaps  ;  latterly,  there  is  paralysis  of  the  extremities  ;  the  breathing 
and  deglutition  become  affected  by  spasms;  the  external  -surface  is  irritable,  and  the  sen- 
sorial functions  are  increased  in  activity  and  perverted  ;  convulsions  may  occur.  These 
symptoms  are  paroxysmal,  they  remit  and  intermit,  and  are  often  excited  by  sight, 
hearing,  or  touch.  The  sullen  form  is  characterized  by  shyness  and  depression,  in 
which  there  is  no  disposition  to  bite,  and  no  fear  of  fluids.  The  dog  appears  to  be  un- 
usually quiet,  is  melancholy,  and  has  depression  of  spirits  ;  although  he  has  no  fear  of 
water,  he  does  not  drink  ;  he  makes  no  attempt  to  bite,  and  seems  haggard  and  suspi- 
cious, avoiding  society  and  refusing  food.  The  breathing  is  labored,  and  the  bark  is 
harsh,  rough,  and  altered  in  tone  ;  the  mouth  is  open'  from  the  dropping  of  the  jaw  ; 
the  tongue  protrudes,  and  the  saliva  is  constantly  flowing.  The  breathing  soon  becomes 
more  difficult  and  laborious  ;  there  are  tremors,  and  vomiting,  and  convulsions. 

Incubation  op  Hydrophobia. — The  wound  by  which  the  poison  is  conveyed 
within  the  body  generally  seems  to  heal  without  any  trouble,  and  the  virus 
may  lie  concealed  for  a  period  of  very  variable  duration,  the  length  of  which 
has  been  estimated  as  ranging  from  three  days  to  seven  years.  Watson  thinks 
that  the  virus  may  be  inclosed  in  a  nodule  of  lymph,  or  detained  in  tempo- 
rary union  with  some  of  the  tissues,  until  some  exciting  cause  sets  it  free  upon 
its  errand  of  destruction.  Virchow  compares  the  action  of  the  poison  to  that 
of  a  ferment  producing  through  the  medium  of  the  circulation  its  specific 
effect  upon  the  nervous  system.  Trousseau  says  that  the  disease  generally 
shows  itself  in  man  from  one  to  three  months  after  inoculation ;  that  cases 
are  rare  after  three  months ;  and  that  the  authenticity  of  cases  reported  as 
occurring  after  the'  lapse  of  a  year  may  well  be  disputed.  [Fereol  has,  how- 
ever, reported  an  apparently  authentic  case  in  which  the  period  of  incubation 
was  two  and  a  half  years.] 

Age  influences  the  period  of  incubation,  this  being  shorter  in  young  people 
than  in  old.  Fleming:  tells  us  that  from  an  estimate  of  ages  from  three  to 
twenty  years,  and  from  twenty  to  seventy -two  years,  it  has  been  found  that 
for  the  first  group  there  is  a  mean  period  of  incubation  of  forty-four  days, 
and  for  the  second  group  of  seventy-five  days.  Faber  adopted  the  view  that 
the  contagious  principle  became  encysted  on  its  introduction  into  the  body, 
and  that  it  entered  the  blood  subsequently  under  the  influence  of  favorable 
conditions. 

Dr.  Anthony  Todd  Thompson,1  in  speaking  of  rabies  from  the  bite  of  a  cat, 
says  that  the  virus  continues  dormant  in  the  part  into  which  it  is  introduced 
by  the  bite  of  the  animal,  Until  a  certain  condition  of  the  system  renders  the 
nerves  in  the  vicinity  of  the  wound  susceptible  to  the  influence  of  the  poison, 
and  that  this  being  communicated,  a  morbid  action  is  begun  in  these  nerves, 
and  extended  to  those  which  preside  over  respiration,  thus  inducing  the  whole 
train  of  symptoms  which  constitute  the  disease. 

1  Medioo-Chirurgical  Transactions,  vol.  xiii.  1826. 


218  HYDROPHOBIA — GLANDERS — MALIGNANT    PUSTULE. 

Symptoms  of  Hydrophobia. — The  symptoms  vary  with  the  peculiar  idio- 
syncrasies of  the  person  inoculated,  and  hence  no  detailed  account  of  them 
can  be  given,  which  shall  apply  accurately  or  even  approximately  to  each  in- 
dividual case. 

Dr.  f)olan  says  that  there  exist  but  two  periods  in  this  disease :  (1)  that  of 
incubation,  and  (2)  that  of  development,  including  all  the  phenomena  between 
the  first  symptom  and  death ;  but  Virchow  has  divided  the  symptoms  of  the 
second  period  into  several  distinct  stages. 

Symptoms  of  the  First  Stage. — In  the  first  stage  of  the  period  of  develop- 
ment, there  are  uneasiness  and  restlessness,  with  stiffness  around  the  neck 
and  throat,  often  nausea  and  vomiting,  and  cerebral  symptoms,  consisting  of 
headache  and  mental  excitement.  These  symptoms,  however,  are  not  of 
invariable  occurrence,  for  the  patient  is  sometimes  suddenly  seized  witli  dif- 
ficulty of  swallowing  liquids.  Local  symptoms  are  sometimes  observed,  but 
in  other  cases  may  be  entirely  wanting.  Irritation  of  the  scar  and  of  the  tis- 
sues in  the  vicinity  of  the  wound,  accompanied  by  darting  pains  of  a  rheu- 
matic character,  is  one  of  the  most  persistent  symptoms.  The  cicatrix  often 
becomes  red  and  inflamed ;  and  if  the  wound  is  still  open,  it  presents  an  un- 
healthy appearance,  and  the  discharge  becomes  thin  and  ichorous. 

The  mental  and  moral  condition  is  at  the  same  time  changed,  the  patient 
being  in  some  instances  troubled  and  anxious  about  the  wound,  and  very 
commonly  becoming  irritable  and  ill-tempered. 

Poland  remarks  that  there  often  exists  a  characteristic  anxiety,  attended 
with  pain  in  the  prrecordia  and  a  sense  of  weight  and  pressure  on  the  chest. 
The  sleep  may  be  disturbed  and  broken  ;  the  patient  suddenly  starting  up  in 
a  frightful  dream,  and  again  sinking  back  in  a  state  of  mental  depression  and 
gloom.  There  is  loss  of  appetite,  no  desire  for  swallowing,  a  feeling  of 
clamminess  in  the  mouth,  with  sighing  and  oppression,  the  patient  breathing 
with  unusually  deep  inspirations.  There  are  attacks  of  chilliness,  with  a 
highly  impressible  state  of  the  system ;  there  is  a  feeling  of  having  taken 
cold  ;  the  voice  is  rough  ;  there  is  a  sensation  of  languor  and  lassitude,  with 
great  weakness  and  heaviness,  and  sometimes  slight  convulsive  movements  of 
the  face  and  limbs ;  there  is  a  remarkable  susceptibility  to  atmospheric  im- 
pressions, the  slightest  contact  of  cold  air  being  a  source  of  great  torture  by 
producing  a  feeling  of  suffocation.  The  poison  is  now  fairly  at  work,  and  in 
a  few  hours,  generally  from  ten  to  twenty-four,  explodes  with  frightful  vio- 
lence. The  period  of  latency  is  now  past,  the  disease  has  reached  its  second 
stage  ;  the  difficulty  of  swallowing  and  the  dread  of  water  fully  establish  the 
presence  of  hydrophobia. 

S'luvptoms  of  the  Second  Stage. — The  second  and  specific  stage  usually  follows 
the  first,  but  sometimes  occurs  without  any  preliminary  warning;  it  begins 
with  stiffness  and  pain  in  the  muscles  of  the  jaw,  throat,  and  base  of  the 
tongue. 

Hypersesthesia  of  the  parts  supplied  by  the  eighth  pair  of  cerebral  nerves, 
i<  now  manifested  by  the  convulsive  spasms  of  the  muscles  of  the  throat, 
which  cause  every  attempt  at  deglutition  to  be  attended  with  pain  and  diffi- 
culty. Hence  the  great  dread  of  food,  and  particularly  of  fluids.  There  is  a 
distressing  dryness  of  the  mouth  and  throat,  often  accompanied  by  a  sensa- 
tion .of  extreme  thirst  which  cannot  he  relieved.  The  secretions  of  the  mouth 
ami  pharynxare  at  first  frothy,  but  soon  become  viscid,  and  cannot  be  ejected 
without  great  I  rouble,  a  hawking  and  barking  noise  being  often  produced  in 
the  attempt.  Tim  violence  with  which  the  patient  spits  is  a  striking  phe- 
nomenon.    Before  long  the  disease  involves  the  muscles  of  the  general  sys- 


MORBID   ANATOMY   OF   HYDROPHOBIA.  219 

tern,  through  the  medium  of  the  spinal  and  cerebral  nerves,  giving  rise  to 
convulsions  which  may  simulate  those  of  tetanus  or  of  epilepsy.  In  this 
stage  of  the  disease  the  pulse  is  rapid  and  quick,  reaching  one  hundred,  and 
thirty,  while  the  temperature  rises  to  one  hundred  and  two,  and  often  to  one 
hundred  and  live  degrees  Fahrenheit. 

There  is  frequent  micturition  ;  the  urine  is  at  first  limpid,  but  afterwards 
becomes  red  and  sanguinolent,  and  Hows  in  small  quantity.  It  contains  renal 
epithelium  and  much  albumen.  It  is  usually  acid  in  its  reaction,  and  con- 
tains an  abundance  of  earthy  phosphates  and  carbonates.  Heated  in  a  tube 
and  cleared  of  the  albuminous  precipitate,  caustic  potassa  and  the  cupro- 
potassic  fluid  discover  reactions  which  reveal  the  presence  of  sugar.  This, 
according  to  some  authorities,  indicates  congestion  of  the  brain  and  spinal 
cord  as  well  as  of  the  kidneys. 

The  patient's  senses  now  become  unnaturally  acute;  the  surface  of  the  body 
is  excessively  irritable ;  the  sight  and  sound  of  fluids  aggravate  the  already 
exasperated  condition ;  and  sometimes  the  slightest  puff  of  air,  or  even  the  smell 
of  particular  substances,  will  induce  a  paroxysm. 

The  mind  is  in  a  singular  condition  of  fear  and  anxiety,  and  the  patient 
experiences  a  dread  of  everything  which  is  either  seen  or  imagined,  culminat- 
ing in  a  state  of  unutterable  despair,  or  sometimes  of  furious  anger.  There  is 
usually  almost  complete  insomnia,  and  the  patient  is  often  unnaturally  talkative. 
There  ma}'  be  insane  impulses  and  delusions,  with  sometimes,  it  is  said,  an 
inclination  to  bite.  The  features  have  a  wild  and  anxious  look ;  the  brows 
are  firmly  knit ;  the  eye  is  staring ;  the  angles  of  the  mouth  are  drawn  ;  and 
the  whole  appearance  is  intensely  haggard  and  ghastly. 

As  the  disease  advances,  both  the  frequency  and  the  severity  of  the  parox- 
ysms are  augmented,  and  the  mental  state  borders  upon  mania.  After  each 
paroxysm  there  is  great  prostration.  The  duration  of  this  second  stage  varies 
from  twenty-four  to  forty -eight  hours ;  seldom  longer. 

Symptoms  of  the  Third  Stage. — -The  third  is  the  paralytic  and  last  stage  of 
the  disease.  It  is  marked  by  the  occurrence  of  rapidly  increasing  depres- 
sion and  exhaustion,  with  subsidence  of  the  paroxysms ;  the  pulse  is  now 
small,  quick,  and  often  irregular ;  the  skin  is  covered  with  a  clammy  sweat, 
the  eyes  look  dull  and  sunken,  and  the  pupils  are  dilated.  The  patient 
rapidly  emaciates;  the  mouth  hangs  open,  allowing  the  saliva  to  escape,  or  if 
it  flows  backward  into  the  throat,  it  causes  a  gurgling  noise,  and  s;ives  rise 
to  a  feeling  of  suffocation  and  choking.  Death  may  take  place  from  asphyxia 
during  a  convulsive  paroxysm,  or  may  result  simply  from  exhaustion. 

All  the  symptoms  have  been  known  to  abate,  and  the  patient  to  sink  into 
a  state  of  repose  and  expire  immediately  on  waking.  The  duration  of  hydro- 
phobia— that  is,  of  its  period  of  development — varies  from  three  to  six  or 
seven  days,  or  in  some  cases  even  longer.  It  has  been  fatal  in  sixteen  hours, 
but  death  generally  occurs  on  the  third  or  fourth  day. 

The  foregoing  description  of  the  symptoms  of  hydrophobia  is  based  upon 
the  writings  of  Poland,  Tanner,  Fleming,  Dolan,  Virchow,  and  other  authors 
who  have  had  practical  experience  in  the  treatment  of  the  disease.  To  use 
the  language  of  Bigelow,  "  In  fact  one  description  is  the  copy  of  another." 

Morbid  Anatomy  of  Hydrophobia. — Dr.  Dolan  writes  that  on  the  loth  of 
May,  1877,  Dr.  Gowers  exhibited  before  the  Pathological  Society  of  London 
a  series  of  microscopic  sections,  illustrating  the  structural  changes  in  the 
medulla  oblongata  and  spinal  cord  in  four  cases  of  rabies. 

In  all  four  cases  the  vessels  of  the  gray  matter  were  greatly  distended,  the  distension 
being  greater  in   the   medulla   near  the  gray  nuclei,  in  the  lowest  part  ot*  the  fourth 


220  HYDROPHOBIA — GLANDERS — MALIGNANT   PUSTULE. 

ventricle.  In  three  of  the  cases,  the  larger  veins  in  this  position  presented  aggrega- 
tions of  small  cells  within   the  perivascular    lymphatic    sheath Similar 

cells  were  scattered  through  the  tissue,  among  the  nerve  elements,  and  in  some  places, 
chiefly  in  and  near  the  hypoglossal  nuclei,  there  were  dense  collections  of  these  cells, 
constituting  in  fact  miliary  ahscesses.  Similar  smaller  collections  were  seen  among 
the  fibres  of  origin  of  the  hypoglossal  and  glossopharyngeal  nerves. 

In  the  paroxysms  of  hydrophobia,  the  respiratory  apparatus  is  wholly 
engaged,  and  in  Dr.  Gowers's  cases  the  structural  change  was  especially  well 
marked  in  the  region  of  the  "  respiratory  centre,"  in  the  medulla;  and  in  the 
case  in  which  the  change  was  most  decided  the  diaphragm  had  been  violently 
affected. 

[Changes  in  the  medullary  and  spinal  cord,  analogous  to  those  observed  by 
Dr.  Gowers,  have  also  been  noted  by  Clifford  Allbutt,  and  by  Cheadle.  Bene- 
dikt,  of  Vienna,  and  Wassilief,  of  St.  Petersburg,  have  found  inflammatory 
changes  in  the  brain,  while  Nepveu  has  noticed  congestion  of  the  nerve-struc- 
tures in  the  neighborhood  of  the  wound,  and  inflammatory  lesions  in  the 
salivary  glands.  Coats,  of  Glasgow,  has  observed  hyperemia  of  the  kidneys, 
with  an  accumulation  of  white  corpuscles.  The  only  characteristic  macro- 
scopic change,  according  to  Cooper  Forster,  is  dilatation  of  the  pharynx.] 

Dr.  Bigelow  states  that  the  structural  changes  noted  in  hydrophobia  are 
not  essential  and  primary  factors  in  developing  the  train  of  symptoms,  but 
are  in  all  probability  secondary  lesions,  resulting  from  the  terrible  disturbance 
which  the  disease  causes  in  the  functions  of  the  respiratory,  vascular,  and 
nervous  systems.  Such  phenomena  can  hardly,  therefore,  be  of  any  value  in 
determining  the  pathogeny  of  the  affection.  He  adds  that  though  we  have 
acquired  new  and  important  data  by  these  observations,  still  we  cannot  affirm 
positively  that  we  have  found  a  characteristic  lesion  pathognomonic  of  hydro- 
phobia.    [Middleton,  of  Glasgow,  entertains  a  similar  view.] 

It  has  been  conjectured,  according  to  Dr.  Hammond,  that  hydrophobia  may 
begin  as  a  blood  disease,  and  end  as  a  nerve  disease.  "  The  nature  of  the 
hydrophobic  virus  is  unknown.  It  is  probably  of  the  nature  of  a  ferment  ;" 
Dr.  Barry,  on  the  other  hand,  in  his  Experimental  Researches,  rejects  the  idea 
that  the  poison  of  hydrophobia  is  absorbed  and  mingled  with  the  blood,  as 
being  directly  opposed  to  all  analogy. 

Diagnosis  of  Hydrophobia. — Dr.  Dolan  well  says  that  the  symptoms  of 
hydrophobia  are  so  characteristic  that  they  should  not  be  confounded  with 
those  of  any  other  disease.  To  distinguish  it  from  tetanus,  Drs.  Holland  and 
Shinkwin  point  out  the  following  differences : — 

(1)  Tetanus  results  from  injuries  of  the  most  varied  character. 

(2)  In  tetanus  the  effects  follow  in  a  very  short  space  of  time,  a  week  seldom 
elapsing  between  the  injury  and  the  development  of  the  symptoms,  while  in  the  one 
hundred  and  twenty  cases  of  hydrophobia  collected  by  Dr.  Holland,  the  shortest  interval 
recorded  between  the  bite  and  the  first  symptoms  of  rabies  was  twelve  days,  the  longest 
three  hundred  and  thirty-four  days,  and  the  average  sixty-one  days  and  eighteen  hours. 

(.'!)  The  anxiety,  horror,  and  convulsions  at  the  sight  of  fluids,  are  not  found  in 
tetanus. 

(4)  In  tetanus,  some  of  the  muscles  are  often  in  a  state  of  rigidity,  and  the  convul- 
sions occur  at  much  shorter  intervals  than  in  cases  of  rabies. 

(5)  Delirium  is  a  very  rare  symptom  in  tetanus,  and  a  frequent  one  in  rabies,  hav- 
ing occurred  eighty  times  in  one  hundred  and  twenty  cases. 

(6)  In  tetanus,  the  secretion  of  saliva  is  seldom  increased. 

(7)  In  tetanus,  the  muscles  of  the  lower  jaw  are  frequently  in  a  state  of  tension. 

(8)  Opisthotonos  or  emprosthotonos  often  terminates  the  case  in  tetanus. 


PROGNOSIS   OF   HYDROPHOBIA. 


221 


(9)  As  Fleming  remarks,  while  physiologically  tetanus  is  a  disease  of  the  true  spinal 
system  of  nerves,  rabies  involves  the  brain  also,  as  is  evinced  by  the  disorder  of  the 
intellectual  functions  and  special  senses  even  early  in  the  disease. 

To  distinguish  hydrophobia  from  oesophagitis,  Dr.  Holland  points  out  these 
essential  differences : — 


In  OESOPHAGITIS. 

1.  Pain  in  the  pharynx,  throat,  or 
along  the  spine  occurs  as  the  earliest  and 
invariable  symptom. 


In  Rabies. 

1.  Pain  in  the  pharynx,  throat,  and 
along  the  spine,  occurred  in  forty-two  out 
of  one  hundred  and  twenty  cases,  or  about 
once  in  every  three  cases,  and  not  as  the 
earliest  symptom. 

2.  The  attempt  to  swallow  fluids, 
though  not  generally  accompanied  by  in- 
tense pain,  causes  dyspnoea,  convulsions, 
etc.,  while  solids  can  be  in  most  cases 
taken  with  comparative  facility. 

3.  Horror  of  fluids  the  most  prominent 
symptom  in  one  hundred  and  nineteen  out 
of  one  hundred  and  twenty  cases. 

4.  No  direct  relation  exists  between 
the  pathological  state  of  the  oesophagus 
shown  after  death,  and  the  intensity  of  the 
dysphagia. 

5.  Saliva  secreted  in  great  quantity, 
often  flowing  spontaneously  from  the 
mouth  ;  these  symptoms  often  occur 
among  the  last  phenomena. 

6.  Thirst  was  urgent  in  about  one-third 
of  the  cases. 

7.  Average  duration  of  the  disease 
seven  days. 

8.  Invariably  terminating  fatally. 

9.  Death  most  probably  resulting  from 
asphyxia,  coma,  or  relapse. 

Fleming  says :  Indeed  it  is  not  possible  to  mistake  hydrophobia  for  any 
other  malady,  or  to  doubt  its  existence  when  it  is  present ;  for  if,  during  the 
stage  of  incubation,  doubts  and  fears  exist,  all  uncertainty  comes  to  an  end 
when  the  disease  really  appears. 

Prognosis  of  Hydrophobia. — Hydrophobia  is  regarded  as  one  of  the  gravest 
of  all  the  maladies  which  afflict  humanity.  It  has  been  asserted  that  we 
have  no  well-authenticated  instance  on  record  of  a  cure  of  this  disease.  Yet, 
Dr.  Dolan  says  that  the  evidence  of  the  recovery  of  cases  of  hydrophobia  is 
as  conclusive  as  the  evidence  that  such  a  disease  exists.  "  To  deny  the  exist- 
ence of  such  records  of  recovery,  is  simply  to  deny  the  existence  of  the  dis- 
ease. We  can  only  know  rabies  by  the  symptoms,  and  by  the  description 
we  have  furnished  by  those  who  have  had  cases  under  treatment.  If  the 
evidence  is  satisfactory  and  conclusive  that  rabies  has  existed,  and,  unfortu- 
nately, been  too  fatal,  it  is  also  equally  satisfactory  and  conclusive  that  Dr. 
Offenburg  has  described  the  disease,  and  attended  a  patient  who  recovered, 
and  that  Dr.  Austin  Flint  has  offered  similar  testimony." 

Dr.  Bigelow  says :  "  The  experiments  made  with  oxygen  by  two  Russian 
physicians,  Drs.  Schmidt  and  Zehender,  with  a  well-authenticated  cure  of  a 
case  of  hydrophobia  from  its  administration,  reported  in  the  Lyon  Midical, 
inspire  the  hope  that  at  last  science  has  struck  the  physiological  key-note, 


2.  The  attempt  at  swallowing  solid  food 
causes  intense  pain,  and  in  aggravated 
cases  swallowing  of  even  fluids  is  accom- 
panied by  pain,  or  may  be  totally  impos- 
sible. 

3.  Horror  of  fluids  reported  to  have 
occurred  in  one  case. 

4.  The  amount  of  difficulty  in  swallow- 
ing is  in  direct  proportion  to  the  extent 
and  intensity  of  the  pathological  appear- 
ances found  in  the  oesophagus. 

5.  Saliva  abundantly  secreted,  expec- 
toration difficult,  and  the  time  of  the 
occurrence  of  these  phenomena  not  fixed. 

6.  Urgent  thirst  in  perhaps  all  cases. 

7.  Average  duration  of  the  disease 
seven  days. 

8.  Generally  terminating  in  recovery. 

9.  Death  caused  by  oedema  of  the  glot- 
tis, gangrene,  or  rupture  of  the  oesophagus. 


222  HYDROPHOBIA — GLANDERS — MALIGNANT    PUSTULE. 

and  that  in  well-established  instances  of  the  disease  the  physician  may  look 
with  a  reasonable  assurance  to  a  successful  termination." 

Treatment  of  Hydrophobia. — The  treatment  of  hydrophobia  resolves  itself 
into  that  which  is  preventive  and  that  which  is  curative. 

Preventive  Treatment. — The  essential  influence  producing  hydrophobia  is 
lodged  in  the  fluid  from  the  rabid  animal's  mouth,  and  not  the  wound  made 
by  the  teeth.  The  first  means  to  be  employed  in  order  to  prevent  the  virus 
from  entering  the  system  is  prompt  suction  of  the  wound,  so  as  in  this  way  to 
remove  the  poison  from  the  part  at  once.  The  bitten  person  should  do  this 
for  himself,  and  should  wash  his  mouth,  after  spitting  out  its  contents,  with 
some  fluid,  and  so  by  continued  sucking  and  washing  get  rid  of  the  poison  as 
far  as  possible.  The  wound,  when  its  situation  permits,  as  when  it  is  in  an 
extremity,  should  be  squeezed  on  its  cardiac  side  at  the  same  time ;  it  should 
also  be  well  washed.  Or  a  strap  or  handkerchief  may  be  applied  tightly 
above  the  wound,  and  a  cupping-glass  be  applied  to  the  part  at  once,  and 
strong  suction  made. 

Cauterization  should  be  practised  as  soon  as  possible,  and  the  best  possible 
means  of  cauterizing  the  part  is  with  the  hot  iron.  A  knife  blade,  a  nail,  or 
an  iron  poker  may  be  used ;  the  iron  should  be  heated  to  a  white  heat,  and 
the  wound  throughout  its  entire  extent  should  be  burnt  with  the  greatest 
thoroughness  and  in  the  shortest  possible  time  after  the  person  has  been 
bitten. 

Dr.  Bigelow  gives  the  following  statement  as  taken  from  Fleming:  In  Al- 
geria, out  of  16  cases  of  immunity,  in  14  the  patients  had  the  wounds  inflicted 
by  rabid  animals  cauterized  more  or  less  promptly  ;  three  persons  were  cau- 
terized twenty-four  hours  after  being  wounded,  and  a  fourth  not  for  thirty- 
six  hours.     The  following  Table  gives  the  details  of  the  16  cases: — 

CASES. 

Immunity  after  immediate  cauterization  with  hot  iron       .         .  7 

"                        "                         "          with  gunpowder           .  1 

"          after  late  appearance  cauterized  with  hot  iron    .         .  1   * 

"          after  at  least  24  hours 3 

"                  "            36     "             1 

"  after  immediate  cauterization  with  muriate  of 

antimony  after  3  hours  ......  1 

"  without  adopting  precautions     .         .         .         .         .2 

In  short,  immunity  in  one-half  of  these  cases  may  be  supposed  to  have 
been  due  to  immediate  cauterization,  in  three-eighths  to  tardy  cauterization, 
while  in  one-eighth  the  patients  escaped  without  any  treatment.  Hugo 
speaks  of  seven  persons  who  were  bitten  by  a  rabid  dog ;  three  had  their 
injuries  cauterized  twenty-four  hours  afterwards,  and  the  four  others  cauter- 
ized themselves  with  two  pieces  of  iron  heated  in  the  fire  ;  all  escaped.  The 
same  dog  attacked  a  child  twelve  years  old,  and,  its  wounds  not  having  been 
attended  to,  it  died  of  hydrophobia. 

Excision  is  strongly  recommended  by  Foot,  Fleming,  Abernethy,  and  others. 
Foot  gives  eight  cases  in  which  excision  was  practised.  In  one  case  it  was 
done  at  once;  in  another,  six  hours  after  the  bite;  and  seventy-two  hours 
■  after  the  bite  was  the  longest  period  in  which  it  was  performed  in  any 
of  the  eight  cases.  If  excision  is  made  dangerous  from  the  neighbor- 
hood of  large  bloodvessels  or  nerves,  caustics  are  recommended.  Nearly 
all  the  caustics  in  use  have  been  recommended  by  different  surgeons  as 
having  been  successful  in  their  hands.     "VVe  must  remember,  however,  that 


TREATMENT    OF   HYDROPHOBIA.  223 

the  immense  majority  of  bites  will  not  be  followed  by  hydrophobia  under 
any  circumstances,  and,  on  the  other  hand,  that  hydrophobia  has  occurred 
after  free  excision  of  the  injured  part.  Mr.  Youatt  had  great  confidence  in 
nitrate  of  silver.  He  was  himself  bitten  seven  times,  and  on  each  occasion 
contented  himself  with  freely  cauterizing  the  wounds  with  nitrate  of  silver. 
[The  daily  administration  of  large  doses  of  bromide  of  potassium,  during 
the  whole  period  of  incubation,  is  strongly  recommended  by  Duboue,  of  Pan.] 

Curative  Treatment. — "When  the  virus  commences  to  evince  its  effects  on  the 
system,  the  second  period,  or  that  of  development,  begins,  and  the  patient 
should  now  at  once  be  placed  in  a  dark  room,  and  kept  as  quiet  as  possible, 
and  free  from  all  avoidable  sources  of  irritation ;  his  strength,  too,  must  be 
supported  by  such  concentrated  food  and  stimulus  as  can  be  taken,  or  by 
nutritious  enemata. 

Dr.  Watson,  of  Jersey  City,1  reports  a  case  which  was  regarded  by  himself 
and  by  Prof.  Austin  Flint  as  a  case  of  undoubted  hydrophobia.  In  this  ease 
a  sixteenth,  a  ninth,  and  a  sixth  of  a  grain  of  curara  were  injected  subcu- 
taneously  at  different  times,  when,  after  the  third  injection,  the  unfavorable 
symptoms  abated,  and  the  patient  entirely  recovered.  Offenburg  and  Polli 
have  also  recorded  instances  of  recovery  from  hydrophobia  under  the  hypo- 
dermic use  of  curara.  Dolan,  too,  gives  the  case  of  a  woman,  aged  24,  who 
was  bitten  by  a  dog  supposed  to  be  rabid,  in  which  case  seven  injections, 
each  containing  one-third  of  a  grain  of  curara,  were  administered  within  four 
hours  and  thirty-five  minutes,  and  the  patient  entirely  recovered. 

In  a  case  of  hj-drophobia,  to  which  I  was  called  in  consultation  by  Dr. 
Carroll,  reported  by  myself  in  the  American  Journal  of  the  Medical  Sciences 
for  April,  1878,  the  spasms  were  relieved  by  the  inhalation  of  nitrite  of  amyl. 

The  case  was  that  of  a  man,  thirty  years  of  age,  who  was  bitten  on  January  1,  1877, 
on  the  back  of  his  left  ring-tinger,  by  a  terrier  dog  which  was  suffering  from  rabies. 
On  the  20th  of  the  following  March,  79  days  after  the  infliction  of  the  wound,  the  scar 
assumed  a  red  and  swollen  look,  and  an  eruption  appeared  on  the  morning  of  the  follow- 
ing day  (March  21),  disappearing  on  the  26th.  On  the  morning  of  the  28th,  the  man 
was  wild  with  excitement;  his  pulse  was  rapid  and  small,  running  at  the  rate  of  140 
beats  to  the  minute ;  his  skin  was  leaky  and  cool,  and  his  countenance  anxious.  He 
made  violent  efforts  to  drink  a  glass  of  milk,  but  was  utterly  unable  to  do  more  than 
grasp  at  it;  he  could  not  possibly  take  hold  of  the  tumbler,  and  entreated  us  in  a  wild 
convulsive  manner  to  take  it  away.  At  this  moment  I  gave  him  25  drops  of  the  nitrite 
of  amyl  by  inhalation.  By  the  time  the  evaporation  of  the  amyl  had  taken  place,  the 
man  said,  "  What  is  that  you  have  given  me  ?  it  is  running  all  around  my  head." 
When  two  or  three  minutes  had  elapsed,  his  pulse  was  found  to  be  88,  and  his  respira- 
tion quite  natural ;  he  appeared  to  be  perfectly  calm.  I  then  asked  him  if  he  thought 
he  could  take  some  milk,  and  he  said  that  he  thought  he  could.  The  milk  was  brought, 
and  he  swallowed  a  pint  with  the  greatest  ease  ;  he  said  he  would  take  some  more, 
when  half  a  pint  additional  was  given  to  him,  with  two  ounces  of  brandy,  and,  when 
he  had  swallowed  it,  he  asked  one  of  the  bystanders  to  give  him  a  drink  of  water. 
The  water  pitcher  was  brought,  and  I  poured  out  a  full  glass  before  him;  when,  taking 
the  glass  as  composedly  as  any  one  could,  he  drank  off  its  contents  with  the  greatest 
comfort,  and  held  the  glass  out  for  more.  I  filled  it  again,  and,  when  he  had  drunk 
nearly  all  the  water,  he  exclaimed,  "  Oh,  but  that's  good  !"  I  sat  with  him  nearly  two 
hours  longer,  during  which  time  he  was  perfectly  composed,  and  got  some  sleep.  Then 
his  pulse  became  more  rapid,  and  his  breathing  more  frequent.  I  asked  him  if  he 
would  take  a  little  brandy  and  water.  The  mere  suggestion  of  the  brandy  and  water 
excited  him  very  much,  and,  when  it  was  brought  near  him,  his  excitement  was  fearful, 
and  he  exclaimed  rapidly,  "  No,  not  until  after  breathing  that  stuff,"  as  he  called  the 

1  American  Journal  of  the  Medical  Sciences,  July,  1873. 


224  HYDROPHOBIA — GLANDERS — MALIGNANT   PUSTULE. 

amyl.  It  was  immediately  gi?en  to  him,  and  had  the  same  happy  effect  as  on  the  first 
occasion  ;  his  pulse  fell,  his  respiration  became  more  calm,  and  he  took  half  a  pint  of 
milk,  three  raw  eggs,  and  half  an  ounce  of  brandy,  which  he  swallowed  very  readily 
and  with  great  comfort.     He  then  fell  asleep,  ana  I  left  him. 

I  returned  the  next  morning  at  9  o'clock,  liaving  asked  Dr.  John  Ashhurst  to  see 
him  in  consultation  with  Dr.  Carroll  and  myself.  We  found  that  our  patient  had  had 
some  sleep,  but  that  for  an  hour  or  more  he  had  been  very  much  excited.  He  could 
not  have  a  glass  of  water  brought  near  him  now  ;  it  was  tried,  and  on  its  approach  he 
shook  convulsively.  Nearly  a  teaspoonful  of  the  nitrite  of  amyl  was  now  administered, 
and  he  again  became  quite  calm  and  drank  nearly  a  pint  of  water,  and  soon  after  took 
some  milk  and  eggs.  At  3  P.  M.,  however,  the  spasms  returned,  and,  on  attempting 
to  give  him  the  amyl,  he  exclaimed  that  he  was  choking,  and  immediately  went  into  a 
convulsion  which  ended  in  death.     No  post-mortem  examination  was  permitted. 

My  friend  Dr.  Solliday,  of  Tamaqua,  administered  the  nitrite  of  amyl  in 
a  case  of  hydrophobia  in  a  girl,  aged  17,  who  was  bitten  by  a  spitz  dog 
which  was  suft'ering  from  rabies. 

The  wound  was  inflicted  on  the  lower  lip,  on  Nov.  26,  1877  ;  the  wound  was  very 
slight,  and  healed  quickly.  On  Dec.  20,  three  weeks  and  three  days  after  the  accident 
had  happened,  hydrophobia  became  manifest.  The  spasms  came  on  every  fifteen 
minutes,  and  the  disease  was  well  developed.  In  the  evening,  twenty-four  drops  of 
the  nitrite  of  amyl  were  given  by  inhalation.  She  now  complained  of  numbness  in  her 
extremities,  and  soon  became  very  calm,  and  remarked  that,  if  the  room  were  quiet, 
she  could  sleep.  At  this  moment  a  glass  of  water  was  given  to  her,  which  she  swal- 
lowed without  trouble.  In  fifteen  minutes  she  was  in  a  quiet  sleep,  which  continued 
for  four  and  a  half  hours.  She  was  awakened  by  a  violent  storm  of  rain  which  made  a 
great  noise  on  the  roof  and  shed  of  the  house  in  which  she  lived.  The  spasms  imme- 
diately returned,  and  were  more  violent  than  at  any  time  previous,  and  continued  until 
death  took  place,  late  in  the  afternoon  of  the  21st.  No  post-mortem  examination  was 
permitted. 

In  both  of  these  cases  the  relief  on  inhalation  of  the  nitrite  of  amyl  was 
very  marked,  and  exceedingly  comforting.  It  relieved  the  spasms  in  both 
cases,  so  that  the  patients  could  drink  both  water  and  milk  to  satiety.  But 
in  neither  case  did  the  amyl  appear  to  stay  the  advance  of  death. 

In  the  Lyon  Medical  there  is  reported  a  case  of  hydrophobia  in  which, 
owing  to  the  experiments  of  Drs.  Schmidt  and  Zehenden  with  oxygen,  that 
gas  was  inhaled,  and  the  disease  disappeared. 

The  case  was  that  of  a  little  girl  bitten  in  the  hand  by  a  rabid  clog.  The  wound, 
after  being  cauterized,  healed  in  a  few  days  ;  but  a  fortnight  afterwards  the  evidences 
of  hydrophobia  were  manifested.  Three  cubic  feet  of  oxygen  were  then  inhaled  by  the 
patient,  and  in  the  course  of  an  hour  and  a  half  the  distressing  symptoms  disappeared, 
and  the  child  became  calm.  Two  days  afterwards  the  symptoms  reappeared ;  there 
were  difficulty  of  breathing  and  swallowing,  and  convulsions  ;  the  oxygen  was  again 
inhaled,  and  at  the  end  of  forty-five  minutes  the  attack  entirely  subsided,  and  never 
returned. 

[Other  modes  of  treatment  which  have  been  recommended  are  the  inhala- 
tion <>f  ether  or  el ilon d'orm;  the  application  of  an  ice-bag  to  the  spine  (Todd, 
Erichsen);  the  persistent  employment  of  a  primary  galvanic^  current  (Ham- 
mond); transfusion  of  blood  (Shinkwin);  and  intra-venous  injection  of  saline 
solutions  ((Silver),  and  particularly  of  bromide  of  potassium  (Duboue).  The 
monobromate  of  camphor  is  also  credited  with  having  effected  a  cure  in  some 
cases,  j 


GLANDERS.  225 


Glanders. 


Glanders  is  a  contagious  and  infectious  disease,  which  appears  also  to  be 
sometimes  spontaneously  generated  in  the  horse,  the  ass,  and  the  mule,  and 
which  peculiarly  belongs  to  those  animals.  While  it  is  a  general  disease,  affect- 
ing the  whole  system,  it  displays  its  greater  force  and  virulenc  e  on  the  mucous 
linings  of  the  nose  and  frontal  sinuses,  and  on  the  submaxillary  glands  and 
lymphatics  of  the  neck  and  ear. 

In  1821,  Mr.  Muscroft,  in  an  article  in  the  Edinburgh  Medical  and  Surgical 
Journal,  described  the  disease  as  existing  in  a  man  who  had  become  inocu- 
lated by  the  dead  body  of  a  glandered  horse ;  and  in  1840,  a  patient  who  had 
been  admitted  into  St.  Bartholomew's  Hospital,  London,  died  of  glanders, 
and  the  nurse  who  had  attended  this  patient  took  the  disease  and  also  died 
of  it.  Many  similar  cases  are  on  record  which  show  that  the  disease,  though 
never  spontaneously  developed  in  man,  can  be  readily  conveyed  to  him,  and 
that,  when  once  inoculated,  it  can  be  easily  communicated  from  one  human 
being  to  another. 

It  is  said  that  the  virus  may  be  communicated  through  the  blood,  and 
Viborg  believes  that  inoculation  may  also  take  place  through  such  secretions 
as  the  saliva,  the  urine,  and  the  sweat.  It  is  well  known  that  the  disease 
may  be  produced  by  wiping  the  hands  and  face  with  cloths  which  have  been 
used  on  an  affected  horse.  13ouley  inoculated  horses  with  the  pus  of  glanders, 
and  though  the  inoculated  parts  were  cut  out  one  minute  after  they  were  in- 
oculated, yet  the  disease  rapidly  manifested  itself.  Villemin,  in  1868,  declared 
his  belief  that  glanders  and  tubercle  were  closely  allied,  and  that  they  should 
be  looked  upon  as  nearly  related  species  of  the  same  genus. 

Symptoms  of  Glanders. — The  disease  manifests  itself  by  an  eruption  of 
tubercles  or  nodules,  and  appears  in  two  distinct  forms.  One  of  these  in- 
volves the  mucous  membrane  of  the  nose  and  the  neighboring  glands,  and  is 
the  form  which  is  particularly  known  as  glanders ;  it  is  termed  morve  in 
France,  and  Rotz  in  Germany.  The  other  form  affects  the  superficial  lym- 
phatics and  absorbents,  either  in  the  trunk  or  extremities,  and  is  characterized 
by  the  development  of  small  tumors  beneath  the  skin,  varying  from  the  size 
of  a  pea  to  that  of  a  walnut,  hard,  fixed,  and  very  painful  when  touched. 
There  is  a  corded  and  knotty  condition  of  the  parts,  whence  this  form  of  the 
disease  is  termed  Warm  by  the  Germans,  and  farcin  by  the  French.  In  Eng- 
land it  is  known  as  farcy-buds.  These  two  forms  are  but  different  types  of 
the  same  disease,  and  they  may  be  found  associated  in  the  same  patient.  The 
period  of  incubation  or  latency  of  glanders  varies  from  two  days  to  a  week, 
after  which  time  the  stage  of  invasion  begins. 

Symptoms  in  the  Horse. — The  following  description  of  the  disease  as  it  is 
observed  in  the  horse,  is  taken  from  Youatt : — 

The  earliest  local  symptom  is  a  nasal  discharge,  which  consists  of  an  increased  secre- 
tion, small  in  quantity,  and  flowing  constantly.  It  is  of  an  aqueous  character,  mixed 
with  a  little  mucus.  It  is  not  sticky  when  first  recognized,  but  becomes  so  afterwards, 
having  a  peculiar  viscidity  and  glueyness.  The  discharge  soon  increases  in  quantity, 
and,  in  the  advanced  stages,  becomes  discolored,  bloody,  and  offensive.  On  the  other 
hand,  the  discharge  may  continue  for  many  months,  or  even  for  two  or  three  years,  un- 
attended by  any  other  symptom,  and  yet  the  horse  be  decidedly  glandered.  The  glands 
under  the  jaw  soon  become  enlarged,  and  are  generally  observed  on  the  same  side  as 
that  on  which  the  nostril  is  affected ;  the  swelling  at  first  may  be  somewhat  large  and 
diffused,  but  this  subsides  in  a  great  measure  and  leaves  one  or  two  glandular  enlarge- 
VOL.  I. — 15 


226  HYDROPHOBIA GLANDERS MALIGNANT    PUSTULE. 

ments,  which  become  closely  adherent  to  the  jaw-bone.  The  mucous  membrane  of  the 
nose  becomes  of  a  dark  purplish  hue,  or  almost  of  a  leaden  color ;  never  the  faint  pink 
blush  of  health,  or  the  intense  and  vivid  red  of  usual  inflammation.  Spots  of  ulcera- 
tion will  probably  appear  on  the  membrane  covering  the  cartilage  of  the  nose  ;  these 
ulcers  are  of  a  circular  form,  deep,  and  with  abrupt  and  prominent  edges,  and  become 
larger  and  more  numerous,  obstructing  the  nasal  passages,  and  causing  a  grating  or 
choking  noise  in  breathing.  The  disease  extends  upwards  into  the  frontal  sinuses,  and 
the  integument  of  the  forehead  becomes  thickened  and  swollen,  causing  peculiar  ten- 
derness. The  absorbents  about  the  face  and  neck  now  become  implicated,  constituting 
farcy;  these  enlarge  and  soon  ulcerate.  The  absorbents  on  the  inside  of  the  thigh,  and 
then  the  deep  absorbents  of  both  hind  legs,  are  next  involved,  causing  these  parts  to 
swell  to  a  great  size,  and  to  become  stiff,  hot,  and  tender.  The  constitutional  symptoms 
are  loss  of  flesh,  impaired  appetite,  failing  strength,  and  more  or  less  urgent  cough  ; 
the  belly  is  tucked  up ;  the  coat  is  unthrifty  and  readily  comes  off.  The  animal  soon 
presents  one  mass  of  putrefaction,  and  dies  exhausted. 

Farcy  as  met  with  in  the  horse  is,  according  to  Mr.  Youatt,  but  a  different 
type  of  the  same  disease. 

Farcy  is  an  affection  of  the  absorbents  and  their  glands,  usually  attacking  the  ex- 
tremities. It  begins  in  a  kind  of  glanderous  chancre,  or  ulcer,  and,  as  the  virus  passes 
along  the  absorbent  vessels,  these  suffer  from  its  acrimonious  quality  ;  hence  the  corded 
veins,  as  they  are  called  by  the  farrier,  or  more  properly  the  thickened  and  inflamed 
absorbents  following  the  course  of  the  veins.  At  certain  distances  in  the  course  of  the 
absorbents  are  valves,  and  these  belly  out,  and  impede  or  arrest  the  progress  of  the 
matter  towards  the  chest.  The  virus  at  these  places  causes  swellings,  which  are  very 
hard,  more  or  less  tender,  and  with  perceptible  heat  about  them.  They  are  observed 
about  the  lips,  nose,  neck,  axillary  spaces,  and  thighs.  Suppuration  and  ulceration 
next  ensue.  The  ulcers  are  rounded,  with  elevated  edges  and  pale  surface ;  and  dis- 
charge a  virus  as  infectious  and  as  dangerous  as  the  matter  of  glanders.  While  they 
remain  in  their  hard  aud  prominent  state,  they  are  called  buttons  or  farcy-buds,  and 
they  are  connected  together  by  the  inflamed  and  corded  absorbents.  The  constitutional 
symptoms  are  drooping,  impaired  appetite,  loss  of  flesh,  and  a  staring  or  prominent 
coat.  The  horse  may  then  rally  and  appear  to  be  restored  to  health,  but  by  degrees 
the  affection  becomes  general ;  the  millions  of  capillary  absorbents  that  penetrate  every 
part  become  inflamed  and  enlarged,  and  cease  to  discharge  their  functions ;  hence  arise 
the  enlargements  of  the  substance  of  various  parts,  swellings  of  the  legs,  chest,  and 
head  ;  these  are  sudden,  painful,  and  enormous,  and  are  distinguished  by  a  heat  and 
tenderness  which  do  not  accompany  other  enlargements. 

Si/mptoms  in  Man. — The  symptoms  of  glanders  in  man,  as  in  the  horse,  may 
he  divided  into  constitutional  and  local.  Soon  after  inoculation,  the  constitu- 
tional symptoms  commence  with  febrile  excitement,  loss  of  sleep,  and  impair- 
ment of  appetite ;  the  patient  suffers  from  chilly  sensations,  alternating  with 
flushes  of  heat;  the  articulations  feel  stiff  and  sore;  the  back  and  limbs  ache  ; 
and  swellings  frequently  appear  in  the  groin,  axilla,  and  neck.  The  fever 
soon  takes  on  a  more  inflammatory  character ;  rigors  ensue ;  diarrhoea  often 
occurs;  and  a  decidedly  typhoid  condition  is  established.  The  pulse  becomes 
quick  and  tumultuous  (108  to  120  beats  in  the  minute);  the  temperature  rises  to 
102  J  or  104°  Fahr. ;  the  tongue  becomes  brown  and  dry ;  and  delirium  sets  in. 
Accompanying  these  symptoms  are  inflammation  of  the  mucous  membrane 
of  the  nose,  with  pain  in  the  region  of  the  frontal  sinuses  and  soreness  in  the 
throat  and  larynx;  the  nose  ana  the  whole  face  become  hot,  tumid,  and  pur- 
ple; the  discharge  from  the  nostrils  is  sanguineo-purulcnt,  copious,  acrid, 
and  excessively  offensive. 

In  five  or  ten  days,  the  second  stage,  or  that  of  eruption,  begins,  and  the 
specific  character  of  the  disease  is  at  once  developed;  when  the  eruption  is 
delayed  for  some  weeks,  the  disease  is  said  to  be  in  a  chronic  form.     The 


TREATMENT  OF  GLANDERS.  227 

eruption  of  glanders  is  hard  and  pustular,  and  resembles  that  of  smallpox. 
Yirchow  thus  describess  the  development  of  the  eruption. 

There  appear  at  first  some  reddish  spots,  which  are  very  small,  and  resemble  flea-bites, 
and  which  soon  acquire  a  papular  elevation,  ultimately  rising  above  the  level  of  the 
surface  like  small  shot,  and  assuming  a  yellow  color.  These  shot-like  knots  are  either 
flat  or  round,  they  do  not  lie  in  a  bladder-like  elevation  of  the  epidermis,  but  in  a  kind 
of  hole  in  the  corium,  as  if  this  had  been  punched  out;  they  are  not  always  solitary, 
but  often  arranged  in  groups.  The  parts  around  are  somewhat  injected,  and  under  the 
epidermis  there  is  found  a  seemingly  consistent  puriform  and  yellow  fluid,  which  is 
chiefly  formed  from  softening  of  the  knots.  These  are  composed  of  a  homogeneous 
yellowish  substance,  which  is  pretty  firm  and  somewhat  brittle,  and  which  has  great 
resemblance  to  tubercle.  Microscopically  examined,  the  knots  present  an  amorphous 
granular  appearance,  and  are  mixed  with  cell  elements  and  cell  growths,  and  with 
numerous  fat  globules. 

The  tubercles  may  be  developed  in  the  subcutaneous  tissue,  producing  hard 
and  painful  swellings,  which  are  oval  and  well  defined.  These  breakfdown 
and  give  rise  to  excessive  sloughing  of  the  parts.  The  tubercles  often  appear 
throughout  the  mucous  membrane  of  the  respiratory  apparatus.  The  kid- 
neys, the  pancreas,  the  testicles,  and  the  liver  may  be  similarly  affected  in  the 
latter  stage  of  the  disease.  In  the  acute  form,  the  disease  is  usually  fatal  in 
a  few  days,  but  in  the  chronic  form,  it  may  last  for  weeks  and  even  months. 
Mr.  Travers  gives  the  history  of  a  case  which,  at  the  end  of  two  years  and  six 
months,  was  still  running  its  course. 

The  acute  form  of  glanders  may  be  accompanied  with  acute  farcy,  in  which 
there  is  generally  diffused  suppuration  in  the  entire  limb.  In  chronic  farcv, 
the  tubercles  often  degenerate  into  foul  ulcers,  and  sometimes  terminate  in  an 
attack  of  acute  glanders. 

Diagnosis  op  Glanders. — In  regard  to  the  diagnosis,  the  early  general 
symptoms  do  not  differ  from  those  of  other  forms  of  animal  poisoning,  while 
in  the  early  period  the  eruption  has  the  shotty  feel  of  smallpox;  but  the 
history  of  the  case  will  almost  always  point  to  the  true  nature  of  the  attack, 
it  being  generally  found,  on  inquiry,  that  the  patient  has  handled  a  glandered 
horse,  or  nursed  another  person  affected  with  the  disease. 

Prognosis. — The  prognosis  in  this  disease  is  always  grave.  The  acute  form 
nearly  always  ends  fatally,  fifteen  cases  collected  by  Rayer  having  given  only 
one  recovery.  The  chronic  form  of  the  disease  is,  however,  not  so  fatal,  ten 
cases  referred  to  by  Rayer  having  given  seven  recoveries  and  but  three  deaths. 
Youatt  declares  that  glanders  does  not  now  produce  one-tenth  part  of  the 
ravages  among  horses  that  it  caused  thirty  or  forty  years  ago,  and  that  generally 
speaking  the  disease  is  at  present  only  met  with  as  a  common  affection  where 
neglect,  filth,  and  want  of  ventilation  are  found. 

Treatment  of  Glanders. — In  the  treatment  of  this  disease,  supporting 
measures  must  be  employed :  Quinine,  tincture  of  the  chloride  of  iron,  and 
brandy,  are  among  the  most  useful  remedies ;  morphia  should  be  used  to  con- 
trol the  pain. 

The  patient's  apartments  should  be  constantly  well  ventilated,  and  the 
utmost  attention  paid  to  cleanliness;  abscesses  should  be  promptly  evacuated, 
and  the  parts  washed  out  with  a  weak  solution  of  chloral  or  of  carbolic  acid, 
and  then  wrapped  up  with  cloths  saturated  with  one  or  the  other  of  these 
fluids. 


228  HYDROPHOBIA — GLANDERS — MALIGNANT   PUSTULE. 


Malignant  Pustule. 

Malignant  pustule  is  a  general  disease  which  originates  from  contact  with 
the  blood  or  tissues  of  diseased  animals,  such  as  sheep  or  horned  cattle,  which 
are  affected  with  murrain.  It  primarily  affects  the  skin  and  connective  tissue, 
appearing  in  the  form  of  a  vesicle,  and  rapidly  developing  gangrene.  The 
disease  at  times  appears  as  an  epidemic  with  a  very  destructive  tendency,  and, 
as  the  virus  is  readily  conveyed  to  horses,  mules,  and  hogs,  immense  numbers 
of  these  animals  are  swept  off  by  its  ravages.  The  virus  is  readily  conveyed 
to  man,  and  the  true  test  of  malignant  pustule  is  found  in  the  fact  that  it  is 
capable  of  being  conveyed  by  inoculation  from  the  human  being  to  the  sheep. 
When  the  virus  from  a  suspected  case  of  the  disease  is  inoculated  in  this  ani- 
mal without  effect,  it  may  be  assumed  that  the  affection  is  not  malio-nant 
pustule. 

From  the  nature  of  their  vocation,  herdsmen,  butchers,  tanners,  and  other 
persons  who  work  among  hides,  and  who  skin  and  eviscerate  the  bodies  of 
animals,  are  liable  to  inoculation  ;  the  virus  is  also  capable  of  being  conveyed 
by  Hies  and  insects  from  diseased  animals  to  man.  The  hands  and  face  are 
the  parts  usually  attacked,  being  most  exposed.  Stone,  of  Massachusetts, 
reported  in  1868  seven  cases  which  occurred  to  persons  working  in  curled 
hair,  and  Bourgeois  relates  the  case  of  a  workman  supposed  to  have  been  in- 
oculated while  picking  the  hair  taken  from  an  old  sofa.  Prof.  Gross  speaks 
of  three  cases  which  occurred  in  persons  who  had  contracted  the  disease  while 
picking  and  eviscerating  buzzards  for  the  purpose  of  extracting  oil  from  those 
birds. 

The  hands  and  forearms  of  each  individual  were  inoculated,  and  violent  local  and 
constitutional  symptoms  appeared  at  the  end  of  two  days.  The  parts  became  excessively 
swollen  and  painful,  and  covered  with  numerous  vesicles,  which,  when  ruptured,  exposed 
ill-looking  ulcers,  which  continued  to  discharge  a  thin,  sanious  fluid,  and  remained 
open  for  many  weeks.  The  inflammation  reached  the  axilla,  and  some  of  the  glands 
of  that  region  became  enormously  enlarged,  and  finally  suppurated.  Prof.  Gross  adds 
that  recovery  took  place  only  after  a  long  time,  and  after  great  suffering,  which  reduced 
the  patient  to  the  utmost  degree  of  exhaustion.  It  could  not  be  determined  whether 
the  poison  was  actually  generated  by  these  birds,  or  merely  conveyed  by  them  through 
their  feathers  being  charged  with  carrion. 

Symptoms  of  Malignant  Pustule. — Malignant  pustule  begins  as  a  red  spot 
followed  by  a  vesicle,  which  soon  becomes  pustular,  and  of  which  the  char- 
ax  -tcristics  are  the  extreme  smallness  of  its  dimensions,  its  being  surrounded 
by  a  vascular  areola  of  leathery  hardness,  its  constant  itching,  and  its  extreme 
sensibility.  The  vesicle  soon  becomes  enlarged,  and  is  rilled  with  a  thin  turbid 
serum;  when  it  becomes  pustular,  it  assumes  a  yellowish-brown  color,  and, 
increasing  in  size,  soon  bursts,  and  exhibits  a  foul  gangrenous  ulcer,  which 
discharges  a  fetid  excoriating  fluid.  While  the  vesicle  is  undergoing  these 
changes,  the  parts  become  greatly  distended  with  serum  and  lymph,  very 
heavy,  numb,  and  painful.  If  situated  on  the  hand,  the  whole  extremity 
becomes  inflamed  as  far  as  the  shoulder,  and  the  axillary  glands  become  in- 
volved. The  number  of  vesicles  may  vary.  In  one  of  the  cases  observed  by 
Prof.  ( Iross,  then'  was  only  one ;  in  another  there  were  two,  one  on  the  hand 
and  one  on  the  forearm  ;  in  another  they  were  so  numerous  that  the  whole 
arm  and  hand  were  literally  covered  with  them.  When  the  disease  appears 
on  the  face,  the  whole  eounteuanee  becomes  dark  and  greatly  distorted;  the 
eyelids  generally  are  closed,  thick,  and  difficult  to  move,  and  the  disease  fre- 


MALIGNANT    PUSTULE.  220 

quently  extends  to  the  throat,  rendering  respiration  and  deglutition  very  diffi- 
cult and  painful. 

The  constitutional  symptoms  which  accompany  these  local  manifestations  are 
well  pronounced :  these  are  general  uneasiness  and  anxiety,  and  afterwards 
high  fever  accompanied  by  rigors ;  a  typhoid  state  soon  follows,  and  septic 
infection  then  becomes  manifest,  from  which  condition,  as  a  general  rule,  few 
patients  recover.  The  disease  is  more  dangerous  when  the  pustule  is  located 
on  the  face  than  when  it  is  on  the  arm  or  hand.  It  frequently  runs  its  course 
in  less  than  a  week  from  the  time  of  inoculation,  and  after  death  rapid  decom- 
position is  apt  to  ensue. 

Pathology  "of  Malignant  Pustule. — Davaine  considers  the  co-operation  of 
specific  organisms  as  proven  in  malignant  pustule,  and  the  investigations  of 
Hodges,  of  Boston,  and  of  late  those  of  Dr.  Robert  Koch,1  appear  to  corrobo- 
rate this  view.  [Dr.  Gerald  Yeo  considers  the  disease  identical  with  that 
known  as  Mycosis  Intcstinalis,  and  believes  that  the  presence  of  an  external' 
pustule  is  not  an  essential  part  of  the  affection.] 

Treatment  of  Malignant  Pustule. — The  treatment  of  this  disease  is  local 
and  constitutional.  With  regard  to  the  local  treatment,  the  pustule  should 
be  destroyed  as  soon  and  as  thoroughly  as  possible,  wherever  may  be  its  situa- 
tion, or  whatever  its  stage  of  development.  The  best  way  to  accomplish 
this,  according  to  Dr.  Devers,  is  lyy  the  application  of  the  actual  cautery  at  a 
white  heat.  This  author  asserts  that  the  white-hot  cautery  has  the  advan- 
tage of  destroying  only  the  part  which  it  touches,  and  that  it  promotes  the 
effusion  of  a  large  quantity  of  serum,  and  induces  the  necessary  reaction  in 
the  adjacent  parts  better  than  any  other  means  which  can  be  employed.  He 
adds  that  if  the  epidermis  is  elevated  by  recently  exuded  serum,  and  separates 
itself  around  the  necrosed  part,  the  cauterization  has  not  been  sufficiently 
deep,  and  must  be  repeated.  Mauserzin2  recommends  the  extirpation  of  the 
pustule  by  the  knife,  and  the  subsequent  application  of  the  hot  iron  to  the 
surface  of  the  wound.  Complete  excision  is  also  recommended  by  Prof.  Gross. 
After  excision  and  cauterization,  the  parts  should  be  enveloped  in  a  warm 
emollient  cataplasm,  and  the  patient  kept  at  rest,  and  supported  with  nour- 
ishing diet. 

The  constitutional  treatment,  when  the  system  becomes  infected,  consists  in 
maintaining  a  constant  supply  of  fresh  air  in  the  patient's  apartment,  and  in 
endeavoring  to  maintain  his  strength  by  the  administration  of  strong  animal 
broths,  and  milk  with  brandy,  while  pain  is  allayed  by  means  of  opiates. 
[Quinia  and  the  mineral  acids  may  also  be  given  with  advantage.  Iodine 
both  internally  and  externally  is  recommended  by  Cezard,  and  carbolic  acid 
by  Estradere.] 

1  On  Traumatic  Infective  Diseases.  Translated  by  W.  Watson  Cheyne,  F.R.C.S.  London,  New 
Sydenham  Society,  1SS0. 

2  Archives  Generales  de  MCdecine,  Mars,  1SG4. 


SCROFULA  AND  TUBERCLE. 


BY 

HENRY  TRENTHAM  BUTLIN,  F.R.C.S., 

ASSISTANT  SURGEON  TO,   AND  DEMONSTRATOR  OF  SURGERY  AT,   ST.   BARTHOLOMEW'S 
HOSPITAL,   LONDON. 


Tubercle. 

Scarcely  any  task  in  medicine  is  now  more  difficult  than  that  of  writing 
clearly  on  Scrofula  and  Tubercle.  The  nature  of  both  diseases,  the  structure 
of  their  morbid  products,  their  relations,  are  all  matters  of  uncertainty  which 
modern  pathology  and  the  microscope  have  not  yet  succeeded  in  rendering 
plain.  Indeed  the  confusion  which  prevails  is  almost  greater  than  that  of 
twenty  years  ago,  in  spite  of  the  excessive  labor  which  has  in  many  countries 
been  devoted,  especially  to  the  subject  of  tuberculosis.  Nor  can  we  yet  be 
certain  whether  this  confusion  may  not  endure  ;  or  whether  out  of  it  we  may 
expect  to  see  order  and  perspicuity  established.  We  cannot  even  define 
either  disease  with  accuracy.  For  there  is  a  total  lack  of  unanimity  of  opin- 
ion respecting  some  of  the  foundations  on  which  an  account  of  scrofula  and 
tubercle  should  be  based.  We  still  hope,  however,  that  from  the  shadowy 
lines  which  now  exist,  some  master-hand  may  form  a  sketch,  perfect  in  all 
its  parts,  firm  and  clear  in  outline,  correct  in  its  proportions,  and  delicately 
toned  in  light  and  shade.  Until  this  has  haply  been  accomplished,  the  only 
course  which  remains  to  each  successive  writer  is  to  sum  up,  as  it  were,  on 
the  evidence  which  is  laid  before  him,  and  to  present  to  his  readers  an  account, 
as  clear  as  he  is  able,  of  each  subject. 

I  shall  depart  from  the  order  usually  observed,  and  shall  treat  first  of 
Tubercle  ;  and  as  I  am  not  able  to  define  tuberculosis,  and  scarcely  know 
how  to  describe  it  in  accordance  with  all  the  most  recent  doctrines,  I  am 
almost  compelled  to  adopt  a  course  which  for  other  reasons  I  prefer : — first, 
to  relate  certain  cases  which  will,  I  believe,  be  regarded  by  almost  all  authors 
as  cases  of  tubercle,  and  then  to  deduce  from  them  an  account  of  the  disease.  ■ 

Case  I — A  girl  15  years  old,  was  admitted  into  St.  Bartholomew's  Hospital  in 
July  of  the  present  year  (1880).  Occupying  the  submaxillary  region  of  the  left  side, 
and  extending  across  the  middle  line,  was  a  greatly  enlarged  lymphatic  gland,  meas- 
uring about  two  and  a  quarter  inches  in  length  by  half  an  inch  in  breadth,  and  as 
thick  as  it  was  broad.  It  was  smooth,  of  oval  shape,  firm  but  elastic,  and  could  be 
moved  with  tolerable  freedom.  Several  of  the  glands  in  close  proximity  to  this  one 
were  enlarged,  but  to  a  far  less  degree.  The  child  was  pale-faced,  with  gray  eyes  and 
fair  hair;  her  skin  not  very  thin,  nor  freckled  ;  her  eyelashes  not  long;  her  superficial 
veins  not  large  or  prominent.  Her  mother  told  us  that  the  tumor  had  existed  in  the 
girl's  neck  for  fully  six  years,  that  no  cause  of  its  origin  had  been  recognized,  and  that 
trom  the  onset  it  had  very  slowly  continued  to  increase  in  size.     It  had  never  been 

(231) 


232  SCROFULA    AND    TUBERCLE. 

painful,  nor  inflamed.  There  was  no  history  of  tubercle  in  the  family ;  and,  with  the 
exception  of  the  tumor  in  her  neck,  the  child  had  always  enjoyed  good  health.  The 
large  gland  and  one  or  two  of  those  which  lay  nearest  to  it  were  removed,  and  the  wound 
healed  as  kindly  as  could  be  desired. 

No  tubercles  could  be  distinguished  in  the  excised  growths  by  the  naked  eye.  They 
presented  the  appearance  merely  of  hypertrophied  lymphatic  glands.  Each  was  in- 
closed in  a  thin  capsule.  The  consistence  of  each  was  a  little  less  firm  than  that  of  a 
normal  gland  ;  the  color  a  little  less  dark.  The  surface  of  a  section  was  finely  granular, 
or  homogeneous,  not  traversed  by  fibrous  bands  ;  and  nowhere  was  there  pus  or  caseous 
material,  or  obvious  degenerative  change.  Had  it  not  been  for  Oskar  Schiippel's1 
treatise,  it  could  scarcely  have  been  suspected  that  these  glands  were  tuberculous.  But 
the  microscope  discovered  in  every  section  numerous  bodies  of  round  or  oval  shape, 
each  consisting  of  a  central  giant-cell  surrounded  by  lymphoid  and  epithelioid  cells, 
inclosed  in  a  delicate  reticulum,  and  the  whole  body  often  surrounded  by  a  kind  of 
fibrous  capsule.  These  tiny  bodies  lay  sometimes  close  together,  but  more  often  sepa- 
rated by  lymphatic  tissue.  In  no  one  of  them  could  vessels  be  distinguished.  Their 
microscopical  characters  corresponded  so  closely  with  those  ascribed  to  tubercle,  that 
the  glands  were  regarded  as  tuberculous  ;  but  in  the  future  consideration  of  this  case, 
it  must  be  borne  in  mind  that  the  diagnosis  rested  solely  on  the  microscopical  exami- 
nation. 

Case  II. — F.  S. ,  a  young  man,  tall  and  thin,  with  brown  hair  and  blue  eyes, 

and  with  full-colored  cheeks,  was  without  any  sign  of  general  ill-health  except  a  slight 
debility,  apparently  due  to  a  restricted  diet  and  rapid  growth,  for  he  was  six  feet  high 
and  had  scarcely  yet  attained  his  majority.  At  the  beginning  of  May,  1880,  after 
jumping  down  from  a  height,  he  noticed  that  his  left  testis  was  enlarged  and  very 
slightly  painful.  It  rapidly  increased  in  size,  but  the  pain  subsided.  He  had  never 
suffered  from  venereal  disease.  His  father  and  his  father's  brother  were  said  to  have 
died  of  consumption.  The  left  testis  formed  a  smooth,  oval  tumor,  about  four  inches 
long,  bulging  somewhat  at  both  ends,  but  presenting  no  indication  of  a  furrow  between 
the  epididymis  and  body  of  the  organ,  which  parts  seemed  blended  or  fused  together. 
The  tumor  was  free  from  pain  or  tenderness.  The  scrotum  was  not  reddened,  but  was 
a  little  puckered  and  adherent  at  the  upper  part.  The  cord  was  slightly  thickened,  but 
no  enlargement  of  the  glands  could  be  distinguished. 

On  the  lGth  of  June,  the  tumor  was  removed.  The  tunica  vaginalis  was  everywhere 
adherent ;  the  epididymis  was  hardly  distinguishable  until  a  section  was  made,  when  it 
was  discovered  to  be  but  little  altered,  save  that  the  globus  major  contained  a  mass  of 
caseous  material.  Almost  the  whole  tumor  was  caseous,  but  moist  and  firm,  not  friable. 
Towards  the  front  was  a  little  juicy  material  of  a  pale  gray  tint,  which  had  not  yet 
degenerated.  No  nodules  or  rounded  bodies  were  visible  to  the  naked  eye.  But 
microscopical  examination  revealed  the  presence  of  many  bodies  resembling  those  found 
in  the  glands  in  the  last  case.  The  giant-cell,  surrounded  by  smaller  cells  in  a  deli- 
cate reticulum,  was  easily  discernible,  but  the  smaller  cells  were  rather  lymphoid  than 
epithelioid,  and  very  few  of  the  tubercles  were  inclosed  within  a  layer  of  fibrous  tissue. 
There  was  a  similar  absence  of  vessels  in  the  tubercles.  The  caseous  material  no  longer 
formed  a  continuous  and  homogeneous  mass,  but  was  for  the  most  part  broken  up  into 
rounded  bodies,  often  of  small  size  and  close  together.  From  the  microscopical  exami- 
nation chiefly,  but  also  from  the  general  appearance  of  the  testis,  the  diagnosis  of 
tubercle  was  made. 

Case  III A  young  gas  fitter,  aged  19  years,  was  admitted  into  the  hospital  in  May, 

1879.  I  lis  mouth  had  been  sore  for  about  two  years,  but  during  the  last  three  months 
his  tongue  had  become  ulcerated.  Six  weeks  before  admission  an  abscess  had  formed 
upon  his  face.  His  health  had  always  been  indifferent,  but  there  was  no  family  history 
of  tubercular  disease.  While  he  was  in  the  hospital,  his  cousin  was  an  inmate  of  the 
same  ward,  convalescent  from  empyema,  and  suffering  from  chronic  inflammation  of 
the  carpus.     The  patient  was  an  ill-nourished,  anaemic  youth,  with  dark  hair  and  eyes, 

1  Untersuchungen  iiber  Lympli-drusen  ;  Tuberculosa     Tubingen,  1871. 


TUBERCLE.  233 

and  a  sallow  complexion.  But  his  lashes  were  not  long,  his  bones  were  small,  and  his 
temperament  was  only  dulled  by  the  severity  of  the  disease.  The  middle  of  the  dorsum 
of  his  tongue  was  occupied  by  an  extensive  ulcer  of  irregular  shape,  not  deep  except  in 
front,  where  it  formed  a  long  fissure  or  deep  cleft ;  its  surface  was  pale  and  smooth ; 
its  border  slightly  raised,  not  undermined ;  and  no  induration  was  present,  of  either  the 
border  or  the  base.  There  were  several  superficial  ulcers  of  the  hard  palate,  and  the 
cervical  glands  were,  many  of  them,  enlarged.  During  the  following  two  months  the 
ulcer  continued,  at  first  slowly,  then  rapidly,  to  enlarge,  and  its  surface  became  foul 
and  sloughy.  The  patient  became  more  and  more  emaciated,  and,  quickly  sinking, 
died  at  length  on  July  23,  1879. 

On  post-mortem  examination,  it  was  found  that  in  addition  to  the  ulceration  of  the 
tongue  and  palate,  and  the  affection  of  the  glands,  the  soft  palate  was  swollen,  ulce- 
rated, and  eaten  out  by  numerous  cavities  containing  caseous  matter.  The  epiglottis 
was  ulcerated,  and  thence  the  ulceration  extended  along  the  aryteno-epiglottidean  folds 
and  down  the  larynx  to  the  true  vocal  cords,  at  which  point  it  was  arrested.  The 
upper  part  of  the  right  lung  was  adherent,  and  hollowed  out  by  cavities  many  of  which 
were  filled  with  blood.  In  the  tissues  of  the  lung,  around  these  cavities,  were  numerous 
bodies  of  small  size  and  gray  or  yellow  color,  or  gray  with  a  yellow  centre.  In  the 
left  lung  existed  collections  of  caseous  matter  varying  in  size.  The  other  organs  of  the 
body  were  normal.  The  diagnosis  of  tubercle  in  this  case  rested  upon  the  characters 
of  the  ulceration  in  the  mouth,  and  upon  the  enlargement  of  the  lymphatic  glands :  it 
was  confirmed  by  the  presence  of  cavities  in  the  lung,  and  of  typical  tubercles  around 
these  cavities. 

Case  IV. — This  series  of  cases  may  be  well  concluded  by  that  of  T.  S.,  a  farm 
laborer,  46  years  old,  who  came  to  St.  Bartholomew's  Hospital  in  March,  1877,  com- 
plaining of  certain  symptoms  of  stone  by  which  he  had  been  distressed  for  upwards  of  a 
year.  During  that  period  he  had  experienced  constant  difficulty  and  pain  in  micturi- 
tion, and  had  often  passed  water  mixed  with  blood.  His  symptoms  had  increased  in 
severity  during  the  last  two  months,  and  the  urine  had  become  turbid;  and  for  three 
weeks  before  admission  his  testes  had  grown  larger,  and  had  been  painful.  Previous  to 
this  illness  the  patient  had  always  enjoyed  good  health.  No  member  of  his  family  had 
suffered  from  consumption.  He  was  a  strong-looking  countryman  who  preserved  the 
appearance  of  health  in  spite  of  the  distress  occasioned  by  his  disease.  He  suffered 
continual  pain  over  the  region  of  the  bladder ;  was  obliged  to  pass  water  at  least  every 
half-hour,  by  day  and  night,  and  each  attempt  at  micturition  was  attended  by  straining 
and  severe  pain.  His  urethra  was  exquisitely  sensitive,  so  that  he  could  scarcely 
bear  the  passage  of  an  instrument,  however  gently  introduced.  But  there  was  no 
stricture,  and  no  stone.  Each  testis  was  enlarged,  and  the  epididymis  especially  was 
hard  and  nodular.  His  symptoms  rapidly  became  more  urgent,  and  to  the  rest  were 
added  others  indicative  of  cerebral  disease. 

On  the  13th  of  April  he  died,  as  it  appeared,  from  inflammation  of  the  brain  or  of 
its  membranes.  But  no  inflammation  was  discovered  after  death,  nor  were  any  tuber- 
cles observed  on  the  membranes  of  the  brain.  Indeed,  to  all  outward  appearance  the 
contents  of  the  skull  were  normal.  The  bladder  wall  was  thickened,  the  mucous  mem- 
brane generally  inflamed  and  ulcerated.  The  right  ureter  was  dilated,  and  its  mucous 
membrane  inflamed ;  and  the  inflammation  extended  into  the  dilated  pelvis  of  the  kid- 
ney, the  secreting  substance  of  which  contained  large  caseous  masses.  The  pelvis  and 
calyces  of  the  left  kidney  were  widely  dilated,  and  scarcely  any  of  its  secreting  struc- 
ture still  remained.  The  epididymis  of  each  side  contained  caseous  masses,  and  in  the 
body  of  each  testis  were  numerous  gray  and  semi-translucent  bodies,  from  the  size  of  a 
millet-seed  to  that  of  a  pea.  The  liver,  spleen,  and  lungs  contained  large  numbers  of 
bodies  bearing  similar  characters,  but  in  the  lungs  many  of  these  bodies  were  of  large 
size  and  yellow,  and  softening  in  the  centre.  Examined  with  the  microscope,  the 
smallest  bodies  generally  contained  a  giant-cell,  and  around  it  lymphoid  tissue  or  larger 
epithelioid  cells  in  a  delicate  reticulum.  In  the  larger  bodies  the  giant  cell  was  re- 
placed by  granular  debris,  which  often  extended  far  beyond  the  area  which  might  for- 
merly have  been  occupied  by  the  giant-cell.  No  vessels  could  be  distinguished  in  any 
of  these  bodies. 


234  SCROFULA  AND  TUBERCLE. 

Analysis  of  the  above  Cases. — Since  each  one  of  these  cases  would  he 
described  by  some  noted  pathologists  as  a  case  of  tubercle,  I  shall  venture 
to  regard  all  of  them  as  tuberculous,  and  to  use  them  for  the  purpose  of 
analysis.  But  if  they  be  compared  together,  it  will  at  once  be  seen  that  they 
do  not  accord  in  many  of  their  prominent  features.  For  example,  the  dura- 
tion of  the  disease  was  in  one  case  twelve  years,  and  the  patient  is  still  alive 
and  well ;  while  in  another  case  it  was  scarcely  more  than  a  year  before  it 
proved  fatal.  The  lesions  were  in  the  first  case  limited  (during  many  years 
at  least)  to  the  lymphatic  glands,  and  even  to  a  certain  group  of  glands;  in 
the  third  case  they  extended  over  a  wide  area  of  the  respiratory  tract,  while 
in  the  last  case  they  were  distributed  over  many  organs  and  tissues.  The 
general  appearances  of  the  lesions  differed  conspicuously,  for  the  disease  of 
the  lymphatic  gland  in  Case  I.  bore  the  characters  of  simple  hypertrophy ; 
that  of  the  testis  in  Case  II.,  those  of  inflammation  with  general  caseous  de- 
generation; and  that  of  the  affected  organs  in  Cases  III.  and  IV.,  the  charac- 
ters commonly  described  as  tuberculous.  The  patients  themselves  presented 
no  common  points  of  resemblance,  in  feature,  in  color  of  hair  and  eyes,  in  com- 
plexion, or  in  general  configuration,  while  their  ages  varied  from  15  to  52 
years.  Clinically,  there  appear  then  to  be  no  characters  which  are  common 
to  them  all ;  no  characters  which  we  can  describe  as  pathognomonic  of  tuber- 
culous disease.  But,  pathologically,  we  discover  in  every  case,  in  some  of 
the  organs  or  tissues,  small  bodies,  generally  of  spherical  or  spheroidal  shape, 
but  apt  to  lose  their  shape  as  they  increase  in  size  or  become  confluent.  The 
larger  of  these  bodies  are  plainly  discernible  with  the  naked  eye ;  indeed  some 
of  them  are  as  large  as  peas  or  even  larger.  The  smallest  can  only  be  discerned 
with  the  aid  of  low  powers  of  the  microscope,  when  they  present  a  similar 
rounded  or  spheroidal  shape. 

Morbid  Anatomy  of  Tubercle. — Here  then  we  seem  to  be  in  possession  of 
the  key  to  all  tuberculous  affections — the  presence  in  the  affected  tissues  of 
small  bodies  of  rounded  or  spheroidal  shape,  which  we  call  tubercles.  But 
in  truth,  at  this  point  the  first  difficulties  arise,  and  the  earliest  departure 
from  apparent  uniformity  occurs.  It  is  impossible  to  rest  content  with  a 
definition  of  tubercle  so  loose  as  this.  We  must  dissect  tubercle,  must 
analyze  it  with  the  microscope  and  describe  its  minute  structure  with  accu- 
racy. We  must  know,  too,  in  what  tissues  it  is  found ;  what  is  its  nature ; 
what  are  the  causes  which  tend  to  produce  it ;  and  the  conditions  in  which 
it  occurs.  On  all  these  questions  there  exists  diversity  of  opinion ;  on  some 
of  them  a  diversity  of  opinion  so  considerable,  that  it  seems  now  as  if  the 
conflicting  views  could  never  be  reconciled. 

Take,  for  example,  the  question  of  the  minute  structure  of  tubercle.  Some- 
times it  appears  to  consist  solely  of  retiform  tissue — of  leucocytes,  or  colls 
resembling  leucocytes,  in  the  meshes  of  a  delicate  reticulum.  Such,  accord- 
ing to  Ziegler,1  is  the  structure  of  those  bodies  which,  with  marked  constitu- 
tional symptoms,  attack  almost  simultaneously  many  tissues  and  organs. 
Sometimes  tubercle  is  composed  of  endothelial  elements,  while  some  tubercles 
again  consist  of  both  these  forms  of  cells.  In  the  centre  of  some  tubercles,  a 
giant-cell  is  found,  irregular  in  shape,  furnished  with  many  nuclei,  and  by 
certain  pathologists  regarded  as  an  essential  element  of  tubercle.  Even  the 
grouping  of  the  nuclei,  when  they  leave  the  centre  free  and  approach  the 
circumference  of  the  cell,  is  thought  to  be  characteristic  of  the  giant-cell  of 
tubercle.     Some  tubercles  are  caseous;  others  are  composed  in  part  of  fibrous 

1  Deber  Tuberculosa  and  Schwindsucht.  Samnilung  klinischer  Vortritge  (Volkmann's),  No. 
1.01,  1678. 


ORIGIN   AND   NATURAL   HISTORY   OP    TUBERCLE.  235 

tissue.  As  with  the  elements  of  which  tubercles  are  composed,  so  with  the 
manner  of  their  combination,  there  is  an  absence  of  uniformity ;  nay,  I  might 
almost  say,  what  appears  to  be  almost  an  absence  of  design,  save  that  we  can 
often  distinguish  a  relation  between  tubercles  of  a  certain  structure,  and  the 
tissues  in  the  midst  of  which  they  lie. 

There  is  indeed  one  feature  in  the  structure  of  these  bodies  which,  I  believe, 
is  admitted  by  all  observers,  the  absence,  namely,  of  vessels  in  their  interior. 
Whether  a  tubercle  be  large  or  small,  whether  it  be  degenerate  or  organized, 
whether  it  be  formed  of  endothelium  or  of  leucocytes,  in  every  instance  it  is 
absolutely  non- vascular. 

Origin  and  Natural  History  of  Tubercle. — As  long  as  uncertainty  pre- 
vails on  the  fundamental  proposition  of  what  is  a  tubercle,  it  seems  idle  to 
discuss  its  origin  and  natural  history.  Yet  no  paper  on  the  subject  would  be 
complete  which  did  not  discuss  these  points,  and  the  only  question  is  how 
they  can  be  considered  here  with  most  advantage.  Perhaps  by  making  an 
arbitrary  definition  of  a  tubercle,  and  using  the  definition  thus  formed  as  a 
basis  on  which  to  build  a  history  of  the  disease.  We  need  not,  however, 
make  a  purely  arbitrary  definition,  but  may  assume  that  the  word  tubercle, 
employed  most  exactly,  signifies  what  is  perhaps  the  commonest  form  of  the 
disease — those  tiny  bodies  which  often  cannot  be  distinguished  with  the  naked 
eye,  but  which  are  discovered  by  the  microscope  to  consist  of  a  central  giant- 
cell  surrounded  by  lymphoid  and  epithelioid  (or  endothelioid)  cells,  contained 
in  the  meshes  of  a  delicate  reticulum.  ISTo  vessels  are  present  within  them. 
These  bodies  may  be  found  within  the  coats  of  small  vessels  (as  in  the  pia 
mater),  or  in  the  various  connective  tissues.  Indeed,  with  the  exception  of 
cartilage,  of  the  connective  tissue  of  the  external  musculature,  and  of  the  coats 
of  the  large  vessels,  in  which  they  have  not  yet  been  discovered  (Frankel),1 
tubercles  may  occur  in  every  part  of  the  body.  They  are  found,  too,  com- 
monly in  connection  with  endothelium,  growing  for  example  about  the  trabe- 
cule of  the  omentum;  but  apparently  they  do  not  grow  in  the  midst  of  epi- 
thelium. 

As  with  the  situation,  so  with  the  origin  of  tubercles.  They  may  arise 
from  the  coats  of  the  smaller  vessels,  from  connective  tissues,  and  from  endo- 
thelium; but  not  from  epithelium,  although  Cornil  and  Ranvier2  have  ex- 
pressed a  contrary  opinion.  They  may  originate  too  from  colorless  blood 
corpuscles  or  wandering  cells,  as  the  glass  disks  of  Ziegler  proved.  Ziegler's 
disks  indeed  proved  more  than  this,  for  they  showed  that  there  was  nothing 
specific  either  in  the  elements  of  the  tubercle  which  we  have  described,  or  in 
the  combination  of  those  elements.  For  the  body  formed  between  these  disks 
corresponded  in  all  its  characters  with  tubercle.  Tubercles,  once  formed,  may 
remain  unchanged  for  a  considerable  time;  or  they  may  enlarge,  and  still  for 
a  time  retain  their  form  and  structure ;  but  more  often  they  become  trans- 
formed. Sometimes  the  transformation  is  degenerative  or  destructive;  the 
central  portion  slowly  becomes  caseous,  or  dies,  probably  from  insufficient 
nourishment  incidental  to  the  crowding  of  its  cells,  and  to  the  absence  of  ves- 
sels within  it;  the  caseation  may  spread  until  the  whole  tubercle  is  involved, 
and  wide  areas  of  caseation  may  be  produced  by  the  degeneration  of  many 
tubercles  in  close  proximity,  and  of  the  intervening  tissues.  Sometimes  the 
transformation  is  towards  organization ;  fibrous  tissue  is  developed ;  indeed  it 
is  not  uncommon  to  find  tubercles  of  the  smallest  size  surrounded  by  a  kind 
of  fibrous  covering. 

1  Tuberculose;  Handbuch  der  Kinderkranklieiten  (C.  Gerhardt).     Bd.  3.  S.  153.     Tubingen, 
1878. 

2  Manuel  d'Histologie  pathologique,  p.  199.     Paris,  1869. 


236  SCROFULA  AND  TUBERCLE. 

Once  formed,  tubercles  are  not  prone  to  disappear  or  to  be  resolved,  although 
Lebert1  states  emphatically  that  tuberculosis  at  all  ages,  in  all  situations,  and 
in  all  places  of  its  development,  is  capable  of  cure.  Far  more  commonly  they 
are  associated  with  inflammatory  changes,  the  tendency  of  which  is  through- 
out destructive.  Suppuration  in  and  about  lymphatic  glands;  disintegration 
and  protrusion  of  the  testis  through  an  opening  in  the  scrotum;  ulceration 
of  mucous  surfaces  and  of  the  skin;  these  are  the  conditions  of  which  tuber- 
cles are  too  often  the  precursors.  These  conditions  are  probably  all  more  or 
less  closely  connected  with  the  caseation  or  molecular  disintegration  to  which 
tubercles  are  so  frequently  subject. 

Infection  of  Tubercle. — But  there  is  another  cause,  more  potent  than  even 
these,  which  tends  to  hinder  or  prevent  the  cure  of  tubercle,  or,  to  speak  more 
justly,  of  tuberculosis.  A  tubercle  once  formed  seems  to  possess  the  power 
of  generating  its  kind.  A  tuberculous  tissue  or  organ  is  not  only  a  source  of 
danger  in  itself,  but  a  source  whence  new  tubercles  may  be  acquired.  The 
spread  of  the  disease  is  not  always  in  the  same  direction,  or  to  the  same  ex- 
tent. Sometimes  it  remains  limited  to  a  single  organ,  which  may  be  com- 
pletely filled  with  tubercles.  An  example  of  this  may  be  found  in  the  testis 
of  the  patient  in  Case  II.,  in  which,  however,  it  must  not  too  hastily  be  assumed 
that  the  condition  was  due  to  the  spread  of  the  disease,  for  there  is  no  distinct 
evidence  to  show  that  all  the  tubercles  may  not  have  been  formed  at  the  same 
moment.  Sometimes  tubercle  invades  a  group  of  organs,  spreading  slowly 
from  the  first  affected  to  the  others.  Such  an  extension  of  tuberculous  dis- 
ease may  fairly  be  supposed  to  have  occurred  in  Case  I.,  where  one  lymphatic 
gland  had  been  diseased  for  many  years,  and  subsequently  each  gland  of  the 
whole  chain  of  glandalce  concatenates,  had  become  enlarged,  and  (if  we  may 
judge  by  the  examination  of  the  smaller  gland  removed)  probably  tuber- 
culous. 

The  infective  material  may  probably  be  conveyed  by  various  channels.  It 
may  be  carried  by  the  small  arteries  from  near  the  root  or  hilum  of  an  organ 
to  its  deeper  parts.  Or  it  may  pass  through  the  lymphatics  to  the  neighbor- 
ing lymphatic  glands,  a  method  of  extension  so  frequent  that  primary  tuber- 
culosis of  certain  parts,  the  tongue  and  pharynx  for  example,  is  invariably 
associated  (provided  that  the  primary  disease  has  been  of  sufficiently  long 
duration)  with  tuberculous  affection  of  the  neighboring  glands.  Or  it  may 
travel  through  the  veins,  and  reach  the  lungs  from  distant  parts,  and  from 
the  lungs  again  be  disseminated  through  the  body.  Examples  of  this  are 
numerous,  but  it  will  be  sufficient  to  cite  Case  IV.,  in  which  the  primary 
disease  was,  it  may  be  believed,  of  the  urinary  mucous  membrane,  and  in 
which,  shortly  before  the  patient's  death,  the  lungs,  the  liver,  and  the  spleen 
became  diseased.  Or,  lastly,  and  this  is  one  of  the  most  common  methods  of 
extension,  the  disease  may  spread  over  the  surface  of  a  membrane  first 
attacked,  or  the  infective  material  be  carried  to  distant  parts  of  long  tracts 
of  membrane,  and  there  produce  new  tubercles.  Illustrations  of  these  condi- 
tions may  be  found  in  Cases  III.  and  IV.  In  the  former,  the  aft'ection  spread, 
as  if  by  continuity,  along  the  surface  of  the  tongue  to  the  pharynx  and  the 
larynx,  and  thence  probably  was  conveyed  by  the  air-passages,  but  without 
infecting  them,  to  the  lungs.  In  the  latter,  the  disease  attacked  the  genito- 
urinary tract,  and,  while  it  spread  over  the  surface  of  the  bladder,  and  through 
the  substance  of  the  kidneys  and  the  testes,  and  was  perhaps  conveyed  from 
one  of  these  organs  to  the  others,  there  were  still  wide  tracts  of  normal  or 
marly  normal  intervening  membrane. 

'  Traite  clinique  et  pratique  do  la  plithisie  pulruonaire,  etc.     Paris,  1879. 


NATURE   OF   TUBERCLE.  237 

Nature  of  Tubercle. — The  uncertainty  which  prevailed  regarding  the 
nature  of  tubercle,  and  the  resemblance  of  some  of  its  processes  to  those  of 
the  malignant  tumors,  led  Virchow,1  many  years  ago,  to  regard  it  as  a  malig- 
nant tumor-formation.  Its  structure,  apparent  incurability,  and  the  manner 
of  its  extension,  were  the  chief  among  the  conditions  which  led  Virchow  to 
adopt  this  view.  Certainly  it  is  an  attractive  theory,  and  may  yet,  perhaps, 
be  proved  to  be  correct  for  some  of  the  bodies  which  are  included  under  the 
name  tubercle.  But  against  its  universal  application,  several  arguments  may 
be  advanced.  First,  the  almost  constant  association  of  the  disease  with 
inflammation — an  association  so  constant  that  tubercle  is  regarded  by  most 
authors  as  the  product  of  inflammatory  changes.  Next,  the  absence  of  ves- 
sels within  the  tubercle,  and  the  wondrous  frequency  of  caseation,  are  both 
unlike  the  characters  of  a  malignant  growth.  Caseation  does  indeed  often 
occur  in  carcinoma  and  sarcoma,  but  not  as  if  it  were  an  almost  necessary 
transformation  of  their  tissues,  or  so  largely  as  to  produce  great  masses  of 
caseous  material.  There  are  some  peculiarities,  too,  in  the  manner  of  infec- 
tion of  the  primary  disease,  in  which  tubercle  differs  from  the  malignant 
new-formations ;  in  the  manner,  for  example,  in  which  it  is  often  scattered 
over  wide  tracts  of  membrane.  And  lastly,  we  can  do  with  tubercle  what 
we  have  not  yet  succeeded  in  effecting  with  any  of  the  malignant  growths: 
we  can  produce  it  at  will. 

Not  in  the  human  subject,  but  in  certain  of  the  lower  animals,  a  body 
closely  resembling  tubercle  in  its  essential  attributes,  may  be  produced  by 
the  introduction  of  certain  substances  within  the  body  of  the  animal.  This 
artificial  tuberculosis  may  be  produced  most  readily  in  the  guinea-pig  and 
dog.  If  we  insert  beneath  the  integument  of  either  of  these  animals,  a  small 
portion  of  degenerated  (caseous)  tubercle,  the  animal  falls  sick  and  dies  within 
a  few  weeks.  Section  discovers  tuberculous  inflammation  of  various  organs, 
notably  of  the  lungs.  Or  if  we  inject  into  the  pleural  cavity  a  fluid  contain- 
ing caseous  particles  from  a  tuberculous  lymphatic  gland,  the  infective  mate- 
rial first  spreads  itself  over  the  surface  of  the  serous  membrane,  producing  at 
numerous  points  nodules  of  induration  (tubercles);  thence  is  conveyed  along 
the  lymphatic  channels  to  the  nearest  glands,  in  which  similar  nodules  are 
produced;  and  by  the  veins  is  disseminated  through  the  body.  The  indurated 
nodules  thus  produced  consist  for  the  most  part  of  masses  of  adenoid  tissue, 
and  do  not  exhibit  the  structure  of  the  typical  tubercle  from  which  "we 
started,  although  in  the  lungs  epithelioid  cells  enter  largely  into  their  compo- 
sition. These  artificial  tubercles,  too,  are  subject  to  much  more  rapid  and 
extensive  caseation  than  are  the  tubercles  of  acute  human  tuberculosis.  And, 
lastly,  it  is  singular  that,  in  the  artificial  tuberculosis  of  animals,  the  brain, 
so  often  the  seat  of  the  disease  in  man,  is  never  attacked. 

These  are  the  chief  differences  between  the  natural  and  the  artificial,  acute 
tuberculosis;  but  they  are  not  sufficient  to  counterbalance  the  evidence  in 
favor  of  the  view  that  the  artificially  produced  disease  is  in  truth  tubercu- 
losis. The  story  of  the  induction  of  tuberculosis  does  not,  however,  end  here. 
The  experiments  of  Sanderson  and  Fox2  have  made  it  clear  that  a  mere  injury 
inflicted  in  a  certain  manner,  may  produce  tubercle  as  surely  as  the  inocula- 
tion or  injection  of  degenerated  tubercle.  For  if  a  seton  be  introduced  into  a 
guinea-pig  or  dog,  or  non-tuberculous  material  be  inserted,  each  of  these  inju- 
ries is  equally  followed  by  the  formation,  locally,  of  a  cold  abscess,  and,  later, 
by  tubercles  similarly  distributed  to  those  which  follow  the  employment  of  a 
tuberculous  agent.     Moreover,  it  has  been  found  that  ouly  certain  animals 

'  Krankhaften  Geschwiilste,  Vorles.  xxi. 

*  Recent  Researches  on  Artificial  Tuberculosis.     Edinburgh,  1869. 


238  SCROFULA  AND  TUBERCLE. 

can  be  rendered  thus  with  ease  tuberculous,  while  others — the  cat,  for  in- 
stance— resist  the  infection,  and  escape  unharmed.  The  lessons  taught  by 
these  experiments  are,  that  tubercle  may  be  artificially  induced ;  that  any 
lesion  which  will  produce  a  cold  abscess,  or,  better  still,  caseation,  may  be  the 
agent  by  which  tuberculosis  may  be  induced ;  that  there  is  nothing  specific, 
therefore,  in  the  infective  material;  but  that,  since  certain  animals  are  easily 
infected,  while  other  animals  as  easily  resist  the  infection,  a  certain  predispo- 
sition to  tubercle  is  probably  essential.  The  characters  of  artificial  tubercu- 
losis lend  great  weight  to  the  theory  of  the  inflammatory  nature  of  the  dis- 
ease, for  all  its  processes  are  apparently  closely  associated  with  inflammation. 

The  bearing  which  these  experiments  have  on  human  tuberculosis  can 
scarcely  be  over-estimated,  and  yet  it  may  be  very  differently  rendered.  If 
tubercle  can  be  produced  in  animals  by  the  introduction  into  them  of  caseous 
material,  whether  tuberculous  or  not,  why  should  not  tubercle  in  man  be  in 
some  such  manner  also  closely  connected  with  the  presence  of  caseous  matter 
in  his  body?  Long  before  the  institution  of  these  experiments  on  animals, 
Buhl1  had  noticed  the  exceeding  frequency  with  which  caseous  masses  occurred 
in  subjects  who  were  tuberculous,  and  had  been  led  on  this,  and  other  ac- 
counts, to  regard  tubercle  as  the  product  of  infection.  He  came,  indeed,  to 
regard  all  tubercle,  whether  acute  or  chronic,  whether  general  or  local,  as  due 
to  the  absorption  of  infective  material  from  caseous  centres.  ISTow,  although 
this  view  cannot  be  maintained  in  the  complete  form  in  which  it  was  advo- 
cated by  Buhl,  it  is,  nevertheless,  with  some  slight  modification,  the  view 
most  commonly  adopted  at  the  present  day.  The  infective  or  absorption 
theory  of  tubercle  assumes  that  all  tubercle  is  produced  by  the  absorption  of 
infective  matter,  but  not  necessarily  of  caseous  matter,  although  caseous 
matter  is  one  of  the  most  powerful  infective  agents.  But  there  are  certain 
difficulties  which  prevent  it  from  being  universally  accepted.  For  example, 
the  centre  of  infection  cannot  always  be  discovered,  even  by  the  most  careful 
seeking — a  difficulty  which  may  be  explained  by  assuming  that  it  has  disap- 
peared, either  by  absorption,  or,  it  may  be,  by  suppuration.  Again,  if  caseous 
matter  be  so  powerful  an  infecting  agent,  how  can  those  cases  be  explained — 
and  they  are  not  few- — in  which  caseous  masses  exist,  or  have  existed,  in  the 
body  for  a  lengthened  period,  and  yet  in  which  no  tubercle  is  produced? 

In  reply  to  this  question,  it  is  suggested  that  a  certain  predisposition  or 
tendency  to  the  formation  of  tubercle  is  necessary,  and,  as  an  illustration  of 
this  law,  the  marked  difference  which  exists  between  certain  groups  of  ani- 
mals in  their  relation  to  tubercle  is  cited — an  illustration  which,  by  the  way, 
loses  something  of  its  point  from  the  fact  that  the  law,  which  in  animals  is 
applied  to  whole  races  or  species,  is  in  man  applied  only  to  individuals.  And 
as  the  insufficiency  of  this  answer  has  been  plainly  felt,  it  has  further  been 
suggested  by  Niemeyer,2  that  the  masses  of  caseous  matter,  to  infect,  must  be 
in  a  certain  stage  or  condition,  and  must  not  be  surrounded  by  a  capsule;  and 
yet  one  more  reason  is  assigned  for  the  infecting  capabilities  of  certain  caseous 
masses,  for  the  infectious  nature  of  certain  sputa — that  they  contain  micro- 
organisms— according  to  Klebs,3  a  form  of  coccus  (the  Monas  tubcrculosum), 
according  to  Buhl,4  bacteria. 

Pathology  of  Tubercle. — These,  then,  are  among  the  problems  which  now 
perplex  pathologists  in  the  nature  and  processes  of  tubercle.  If  we  are  com- 
pelled to  hold  fixed  views  on  any  of  them,  those  which  suggest  themselves  as 

1  Lungenentziindtmg,  Tnborknlose  mid  Schwindsucht. 

2  Text-book  of  Practical  Medicine,  translated  by  Humphreys  and  TIackley. 

3  Handbuch  der  pathologisclien  Anatomie.  *  Op.  cit. 


TREATMENT  OF  TUBERCLE.  239 

most  acceptable  and  worthy  of  credence  are  that  tubercle,  in  its  most  perfect 
form,  possesses  such  a  microscopic  structure  as  that  which  we  described  in 
defining  it;  that  some  tubercles  never  attain  this  complete  or  typical  struc- 
ture, while  others  either  degenerate  or  become  further  developed ;  that  devia- 
tions from  this  type  may  and  do  occur,  in  accordance  with  the  situation  in 
which  a  tubercle  is  found ;  that  tubercle  is  an  inflammatory  production,  not 
a  malignant  growth  (as  sarcoma  and  carcinoma  are  malignant);  that  a  tuber- 
culous tissue  or  organ  is  a  centre  whence  tubercle  may  be  conveyed  through- 
out the  body;  that  the  channels  by  which  the  conveyance  is  effected  arc 
several ;  that  tubercle  may  be  produced  in  the  bodies  of  certain  individuals 
by  the  absorption  of  an  infective  material.  But  the  evidence  which  is  fur- 
nished on  the  more  advanced  questions  is  not  yet  sufficiently  convincing  to 
permit  us  to  form  a  decided  opinion  on  them.  We  cannot  yet  assign  to  each 
tubercle  its  value.  We  cannot  be  sure  whether  all  tubercles  are  due  to  the 
absorption  of  infective  material,  or  whether  they  sometimes  own  another 
cause.  Xor  can  we  say  with  certainty  whether  the  infective  material  is  sim- 
ple, or  whether  it  is  specific.  And  although  we  may  admit  that  a  predispo- 
sition to  tubercle  is  necessary  ere  it  can  be  developed,  we  are  not  yet  in  a 
position  to  define  the  nature  of  this  predisposition.  A  few  years  ago,  inherit- 
ance was  regarded  as  one  of  the  chief  predisposing  causes  of  tuberculosis. 
Now,  it  is  said  that  tuberculosis  is  not  inherited,  but  that  the  offspring  in- 
herits from  the  parent  a  tendency  to  the  production  of  caseous  masses,  from 
which  tubercle  may  be  developed.1 

Treatment  of  Tubercle. — The  tuberculous  affections  in  which  surgery  is 
mainly  interested,  are  those  of  which  examples  have  been  given;  of  the 
tongue,  the  pharynx,  the  glands,  the  urinary  mucous  membrane,  and  the 
testis.  The  bones  or  periosteum,  and  the  synovial  membranes,  may  be  added 
to  the  list,  while  tubercle  of  the  larynx  and  the  choroid  are  more  likely  to 
be  met  with  in  the  practice  of  the  special  surgeon,  or  the  physician. 

It  is  not  intended  that  this  article  should  comprise  a  detailed  account  of 
the  tuberculous  affections  of  each  part.  These  will  be  treated  of  in  subse- 
quent pages  devoted  to  the  study  of  the  special  organs  and  tissues.  It  now 
only  remains  therefore  to  indicate  the  main  lines  on  which  the  treatment  of 
tuberculous  disease  is  founded.  Treatment  is  directed  not  only  to  the  cure 
of  those  who  are  tuberculous,  but  to  the  prevention  of  tuberculosis.  For  our 
wider  knowledge  of  the  etiology  of  the  disease,  and  of  the  course  which  it 
may  not  improbably  pursue,  leads  us,  not  unnaturally,  to  adopt  those  meas- 
ures which  seem  calculated  best  to  avert  its  cause,  and  to  arrest  its  progress. 
We  believe  that  the  offspring  of  tuberculous  parents  are  predisposed  to 
tubercle.  We  cannot  prevent  the  parents  from  begetting  children,  but  we 
can  place  many  of  the  children  in  conditions  which  will  diminish  their  lia- 
bility to  tubercle.  By  careful  hygiene,  by  clothing  and  by  food,  we  may 
lessen  the  number  of  the  tuberculous  among  the  children  of  the  poor;  while 
for  the  children  of  the  more  wealthy  classes,  in  addition  to  these  things,  each 
should  be  advised,  if  possible,  to  select  a  calling  which  will  not  subject  him 
to  frequent  or  long-continued  strain,  or  expose  him  to  continued  cold  and 
wet.  Residence,  too,  in  places  where  the  air  is  clear  and  dry,  and  the  winter 
not  too  long  or  cold,  should  be  strongly  recommended.  When  tubercle  is 
actually  present,  to  these  measures  are  generally  added,  often  with  the  best 
result,  the  administration  of  certain  drugs,  the  beneficial  influence  of  which 
over  the  progress  of  tubercle  has  long  been  recognized.  Cod-liver  oil  and 
syrup  of  the  iodide  of  iron  are  exhibited  with  bark  and  alkalies,  or  acids,  as 

1  Billroth  ;  Pitlia  und  Billrotli's  Haudbucli  der  Chirurgie  ;  Bd.  I.,  Abth.  2,  Hft.  1,  S.  307- 


240  SCROFULA  AND  TUBERCLE. 

may  seem  best  to  meet  the  requirements  of  each  individual  ease.  For  we 
believe  that  tubercle,  however  rarely,  is  capable  of  cure;  both  because  persons 
who  have  seemed  to  suffer  from  tuberculosis  of  the  lungs,  have  recovered, 
and  because  ulcers  of  the  mouth  and  pharynx  which  have  borne  the  typical 
tuberculous  aspect,  have  been  watched  as  they  slowly  but  completely  healed. 
But  when  a  limited  area  which  is  easily  accessible,  is  tuberculous,  and  there 
is  no  evidence  that  the  disease  affects  more  distant  parts,  it  seems  but  reason- 
able, in  appreciation  of  the  infectious  nature  of  the  disease,  to  cut  away  the 
affected  portion  as  if  it  were  a  malignant  growth.  Of  late  years  this  has  been 
done  with  tolerable  frequency.  The  testis  has  been  thus  treated,  and  so  have 
tuberculous  ulcers  of  the  tongue,  and  tuberculous  affections  of  the  bones  and 
joints.  Of  the  propriety  of  all  these  operations,  there  can  be  no  doubt,  pro- 
vided that  they  are  undertaken  in  fitting  cases  and  performed  with  all  due 
care.  But  opinion  is  not  so  unanimous  as  to  the  advisability  of  removing 
lymphatic  glands  containing  tubercles.  For,  although  the  disease  may  remain 
long  limited  to  a  certain  group  of  glands,  it  is  not  often  limited  to  a  single 
gland,  but  quickly  spreads  from  one  to  another.  A  whole  group  of  glands 
can  rarely  be  removed,  especially  as  the  cervical  glands  are  those  which  tuber- 
cle most  commonly  affects.  And  if  one,  perhaps  the  largest,  of  a  certain 
group  be  taken  away,  the  operation  so  far  from  being  beneficial  may  even 
prove  the  reverse  by  exciting  to  activity  the  morbid  process  in  the  glands 
still  left  behind.  A  case  illustrating  this  is  that  of  a  girl  twelve  years  old, 
who  for  two  or  more  years  had  suffered  from  a  tuberculous  gland  in  the  middle 
line,  beneath  the  floor  of  the  mouth.  Sometimes  it  suppurated,  and  unhealthy 
ulcers  formed;  and,  again,  the  openings  closed  and  all  bid  fair  for  cure.  But 
the  lump  remained,  and  was  a  constant  eyesore  and  source  of  annoyance  to 
the  patient.  I  removed  it,  therefore,  with  all  due  care,  and  the  wound  healed 
by  the  first  intention.  Now,  however,  the  neighboring  glands,  which  before 
the  operation  had  been  quiescent  and  scarcely  at  all  enlarged,  quickly  grew 
larger,  and,  suppurating,  formed  scars  and  ulcers,  more  distressing  and  dis- 
figuring than  the  disease  which  I  had  removed.  Further  experience,  based 
on  numerous  observations,  is  required  to  decide  as  to  the  propriety  of  ope- 
rating under  such  circumstances. 


Scrofula. 

Two  cases,  shortly  recounted,  will  serve  to  preface  the  description  of 
Scrofula.  Each  of  them  is  typical  in  its  kind,  yet  it  will  be  seen  that  the 
difference  is  great  between  them. 

Case  V The  first  is  that  of  a  boy,  twelve  years  old,  who  came  to  my  Out-Patient 

room  nearly  two  years  ago  (February,  1879),  with  a  swelling  of  the  back  of  one  hand. 
He  was  a  well-grown  lad,  with  fair  hair,  blue  eyes,  and  a  ruddy  glow,  as  if  of  health. 
His  skin  was  not  very  thin  or  freckled,  nor  was  it  so  transparent  as  to  permit  the  super- 
ficial veins  to  be  seen  clearly  through  it.  The  swelling  of  his  hand  had  followed  almost 
immediately  upon  a  blow.  It  occupied  the  whole  of  the  dorsum  of  the  hand,  but  was 
most  prominent  over  the  third  metacarpal  bone,  where  the  skin  was  reddened,  hot,  and 
tender.  For  many  days  or  weeks  it  changed  but  little  ;  then  slowly  suppurated  ;  and 
:it  the  bottom  of  thfl  suppurating  cavity  bare  bone  was  easily  distinguished.  After  a  while, 
almost  the  whole  of  the  metacarpal  bone  was  removed  by  operation,  and  there  seemed 
to  be  no  reason  why  the  wound  should  not  fill  up  by  granulations  and  become  a  healthy 
gear.  Bu|  the  progress  towards  recovery  was  marvellously  slow.  The  wound  appeared 
to  flag)  apd  sinuses  burrowed  through  to  the  palm  ;  yet  the  general  characters  of  good 
health  were  preserved,  and  no  new  local  mischief  in  the  bones  or  joints  was  discovered. 
At  the  end  of  a  year  of  treatment,  the  hand  was  still  unhealed.     And  now  two  ulcers 


NATURE   OF   SCROFULA.  241 

formed  immediately  above  one  elbow  ;  of  circular  shape  ;  with  glazed  or  waxy  surface, 
but  discharging  an  abundance  of  thin  pus;  with  edges  of  a  dull  red  color,  thin  and 
widely  undermined  ;  and  with  congested  integument  around  and  between  them,  for  they 
lay  not  far  apart.  A  few  weeks  later,  an  abscess  formed  on  the  dorsal  aspect  of  one 
foot,  broke,  and  discharged  a  thin  but  curdy  pus.  Abscess,  sinuses  and  ulcers,  dis- 
charging all  together,  produced  at  length  a  sensible  effect  on  the  patient's  health,  in 
spite  of  good  food,  cod-liver  oil,  and  preparations  of  iron  and  iodine.  He  was  therefore 
sent  for  a  while  to  the  seaside,  and  when  he  returned,  already  benefited  by  the  change, 
was  taken  on  board  his  father's  barge  that  he  might  enjoy  the  river  air  the  whole  day 
long.  Slowly  the  discharge  diminished  and  the  wounds  began  to  heal,  and  after  several 
weeks  some  of  them  were  really  closed,  and  his  general  health  improved.  After  which 
he  ceased  to  attend  the  Hospital. 

Cask  VI. — The  second  case  occurred  in  a  very  different  subject — a  woman,  whose 
age  was  only  fifty-nine,  but  who  was  prematurely  old.  She  was  white-haired,  anaemic, 
weak,  and  withered.  The  first  phalanx  of  her  left  forefinger  was  greatly  enlarged,  and 
covered  with  thin,  red  skin,  glazed  and  ulcerated.  Sinuses  passed  directly  into  the  inte- 
rior of  the  bone,  which  was  as  if  blown  out  into  a  thin-walled  cavity,  containing  a  soft 
material  in  which  were  numerous  grits  of  bone.  On  the  upper  aspect  of  each  foot  was 
a  circular  ulcer,  with  thin,  red,  undermined  edges,  through  which  rough  and  carious 
bone  could#  be  reached.  And  over  the  left  patella  were  two  small  ulcers,  implicating 
the  skin  and  subcutaneous  tissue,  but  not  connected  with  disease  of  bone.  Her  history 
was  free  from  any  record  of  specific  disease.  She  had  been  always  delicate,  and  about 
five  years  ago  had  become  completely  blind  from  amaurosis.  Within  the  last  two  years, 
abscesses  and  ulcers  had  formed,  first  on  the  finger  and  then  on  the  feet ;  and  tiny  frag- 
ments of  bone  had  come  away  at  intervals.  She  was  kept  under  observation  during 
several  weeks,  and  was  well  fed  and  warmly  clad.  Quinine  and  iron  were  administered, 
and  the  wounds  were  dressed  with  a  slightly  stimulating  ointment.  But  she  made  little 
or  no  progress  towards  recovery. 

Xature  of  Scrofula. — To  complete  the  account  of  scrofula  by  clinical 
illustrations  would  require  many  more  cases  than  these,  but  these  two  patients 
presented  certain  common  features  of  disease  which  are  almost  universally 
regarded  as  scrofulous.  In  both  of  them  inflammation  was  set  up  by  an  ex- 
citing cause  so  trivial  that  only  in  one  could  it  fairly  be  assigned.  In  each 
case  the  inflammation,  thus  excited,  proceeded  to  suppuration ;  and  ulcers 
were  formed,  the  characters  of  which  were  for  the  most  part  of  a  certain 
definite  type.  The  disease,  once  established,  exhibited  a  disposition  to  main- 
tain its  hold ;  the  affection  of  the  bones  slowly  progressed  to  their  partial 
or  complete  destruction ;  the  ulcers,  if  they  did  not  spread,  certainly  did  not 
heal ;  and  several  regions  of  the  body  became  the  seat  of  similar  disease. 

In  these  few  sentences,  scrofula  is  almost  defined,  as  far  indeed  as  it  ap- 
pears capable  of  definition ;  for  the  essence  of  the  disease  lies  rather  in  several 
tendencies  or  predispositions,  than  in  any  clearly  defined  conditions.  In  the 
two  cases  recorded,  for  example,  there  was  nothing  so  characteristic  in  the 
signs  or  course  of  the  inflammations,  but  that  it  might  be  imitated  in  the 
inflammations  of  those  who  are  not  suffering  from  scrofula.  Xor  were  the 
ulcers  such  that  they  could  be  at  once  and  certainly  distinguished  as  scrofu- 
lous. Yet  no  one  would,  I  imagine,  be  disposed  to  deny  that  these  patients 
were  suffering  from  scrofula.  For  scrofula  may  be  described  as  a  condition 
of  the  body,  or  of  certain  portions  of  the  body,  in  which  inflammations  are 
easily  excited  ;  in  which  the}^  tend  towards  suppuration  and  ulceration ; 
and  in  which  the  power  of  spontaneous  recovery  is  very  feeble.  It  has  been 
defined  by  Virchow1  as  consisting  in  "a  greater  vulnerability  of  parts  and  a 
greater  pertinacity  of  disturbances,"  than  is  natural,  and  these  expression*; 
form  the  basis  of  the  large  majority  of  later  and  longer  definitions. 

Yqt    j ic  l  Krankliaften  Gescliwulste,  Vorles.  xxi. 


242  SCROFULA  AND  TUBERCLE. 

Morbid  Anatomy  of  Scrofula. — There  is  not  in  scrofula,  as  in  tubercle,  a 
pathological  body,  either  microscopical  or  of  larger  size,  peculiar  to  the  dis- 
ease. All  the  changes  are  those  of  inflammation,  but  the  products  of  scrofu- 
lous inflammations  may  be  analyzed,  chemicall}'  and  histologically,  without 
the  discovery  of  any  substance  or  structure  which  may  not  equally  occur  in 
any  or  indeed  in  every  inflammation.  One  thing  certainly  is  noticed  of  the 
lymph  produced  in  scrofulous  inflammations ;  not  only  that  it  tends  to  sup- 
purate, and  is  little  prone  to  organization,  but  that  it  has  a  very  strong 
tendency  to  degenerate  into  caseous  material,  by  absorption  of  the  fluid  parts, 
and  by  withering  and  distortion  of  the  cells.  These,  mixed  together,  form  a 
yellow  substance  in  which  fatty  molecules  abound,  and  in  which  plates  of 
cholesterine  and  the  debris  of  tissues  which  'have  been  disorganized  are  found. 
But  caseation,  although  it  is  so  common,  is  not  a  constant  result  of  scrofulous 
inflammation.  And  even  if  it  were  so,  it  is  a  condition  so  frequently  occur- 
ring in  connection  with  other  forms  of  inflammation,  the  tuberculous,  for 
example,  that  it  could  not  be  regarded  as  in  any  way  distinctive  of  scrofula. 
The  abundance  of  lymphatic  elements,  too,  which  has  been  noticed  by 
Frankel1  in  scrofulous  inflammations,  is  not  more  distinctive  of  them  than  is 
caseation. 

Diagnosis  of  Scrofula. — Although  scrofula  is  a  disease  thus  difficult  to 
define,  and  though  its  lesions  are  not  separated  by  any  well-marked  limit 
from  those  which  may  result  from  other  debilitating  diseases,  it  is  never- 
theless not  difficult  to  diagnose  in  such  instances  as  the  two  which  I  have 
described.  Even  in  less  advanced  cases,  it  may  be  recognized  by  certain 
characters  presented  in  its  lesions,  which  though  they  are  not  pathognomo- 
nic, are  more  uniformly  observed  in  scrofulous  affections  than  in  any  other. 
Let  us  leave  for  a  moment  the  tissues  and  organs  which  are  the  seat  of  dis- 
ease, and  examine  the  characters  of  the  lesions  wherever  they  occur. 

The  inflammations  are  very  slow  in  progress,  lingering  often  for  weeks 
before  suppuration  is  established.  Yet  the  signs  by  which  they  are  accom- 
panied are  sometimes  almost  acute ;  the  superficial  redness  is  intense,  the 
swelling  considerable,  the  pain  extreme,  and  even  the  heat  is  notably  in- 
creased. All  the  signs  predict  an  early  suppuration  and  quick  recovery. 
But  the  prediction  is  not  fulfilled,  for  even  the  suppuration  appears  un- 
accountably delayed.  Far  more  frequently,  however,  all  the  signs  of  inflam- 
mation are  chronic  throughout,  and  the  abscess  which  results  is  cold  or 
lymphatic.  Yet  even  these  abscesses  often  point,  and  break  with  superficial 
redness,  and  heat,  and  pain.  The  ulcers  of  scrofula  are  generally  circular  in 
form  ;  with  red  or  livid  edges,  not  raised  and  scarcely  thickened,  but  under- 
mined sometimes  over  a  wide  area;  with  pale  and  flabby  granulations,  often 
large  and  flattened;  and  with  an  area  of  chronic  congestion  surrounding 
them.  The  discharge  from  these  ulcers  is  generally  abundant,  but  thin  and 
watery.  They  remain  apparently  unchanged  in  size  or  characters  for  weeks, 
or  even  months,  or,  under  unfavorable  conditions,  grow  larger;  and,  where 
several  of  them  lie  not  far  apart,  gradually  approximate  until  they  are  only 
separated  by  thin,  undermined  bands  or  strips  of  red  integument,  or  join  to 
form  larger  sores  with  incurved  borders.  Even  the  sears  which  remain  after 
healing,  nre  characteristic  of  the  disease.  They  are  strangely  puckered  and 
distorted,  often  presenting  prominent  crests  or  ridges,  and  retaining  the  dull 
red  or  livid  hue  of  the  borders  and  surrounding  ureas  of  the  ulcers.  Occa- 
sionally the  thin  belts  between  the  ulcers  fail  to  become  united  with  the  sub- 
jacent healing  surface,  but,  maintaining  their  vitality,  heal  separately  and 

1  Handbuch  der  Kinderkrankheiten  (C.  Gerhardt),  Bd.  iii.  S.  120.     Tubingen,  1878. 


TISSUES   AND   ORGANS   AFFECTED   BY   SCROFULA.  243 

remain  as  thin,  clastic  strips  of  skin,  attached  at  each  end  and  bridging  over 
a  slightly  depressed,  scarred  surface.  The  disfigurement  produced  by  these 
scars  is  often  most  distressing,  especially  when  they  occur,  as  they  are  apt  to 
do,  about  the  face  and  neck. 

Tissues  and  Organs  affected  by  Scrofula. — The  affections  due  to  scrofula 
are  unfortunately  very  numerous.  Eczema  and  lichen  affect  the  skin — not 
always  readily  recognizable  as  scrofulous,  unless  associated  with  other  lesions, 
bat  always  obstinate  and  difficult  to  treat.  Still  more  intractable  and  more 
destructive  than  these  eruptions,  but  with  a  pathology  less  clear,  is  the  lupus 
called  scrofulous  or  tuberculous,  which  occurs  so  frequently  about  the  upper 
lip  and  nose.  Ulcers  and  abscesses,  bearing  the  characters  just  now  described, 
attack  the  skin  and  subcutaneous  tissue ;  and  chronic  inflammation  and  sup- 
puration, the  lining  membrane  of  the  cavities  and  passages  of  the  nose  and 
ear — often  with  the  permanent  establishment  of  ozsena  and  otorrhcea.  Inflam- 
mation affects  the  follicles  of  the  eyelids  ;  chronic  and  phlyctenular  inflamma- 
tions the  conjunctiva  and  even  the  cornea,  leading  to  irritable  ulcers  which 
too  frequently  result  in  scars  injurious  to  the  sight.  The  tonsils  are  often 
permanently  large  and  prone  to  inflammation,  and  sometimes  a  deeper  and 
more  extensive  ulceration  occurs  about  the  fauces,  which  can  with  difficulty, 
if  indeed  at  all,  be  distinguished  from  tuberculous  angina.  The  mucous 
membrane  of  the  larynx  and  trachea  is  not  uncommonly  the  seat  of  inflamma- 
tion ;  and  bronchitis  and  pneumonia  attack  the  lungs.  The  vaginal  mucous 
membrane  of  scrofulous  girLs  is  occasionally  the  scat  of  chronic  congestion 
and  discharge. 

But  of  all  structures,  the  lymphatic  glands  are  perhaps  most  frequently 
affected  by  scrofulous  inflammations.  Those  of  the  neck  are  so  often  thus 
inflamed,  that  chronic  enlargement  of  them  has  come  to  be  regarded  as  nearly 
the  most  important  sign  of  scrofula.  In  some  cases,  but  a  few  glands,  those 
behind  the  ear  and  sterno-mastoid,  for  example,  are  enlarged,  while  in  other 
instances  the  whole  chain  of  glands  on  either  side  is  implicated.  The  mere 
fact  of  enlargement  of  the  lymphatic  glands  cannot,  however,  be  regarded  as 
a  sign  of  scrofula,  for  (1)  non-scrofulous  inflammations  are  common,  especially 
in  the  neck,  where  so  many  causes  may  exist  to  induce  secondary  affection  of 
the  glands ;  and  (2)  the  cervical  glands  are  those  which  are  chiefly  liable  to 
non-inflammatory  diseases,  of  which  examples  may  be  found  in  lymphade- 
noma  and  lymphosarcoma.  To  add  to  the  difficulties  of  early  diagnosis,  the 
scrofulous  inflammations  of  glands  probably  rarely  or  never  arise  spontane- 
ously, but  are  always  secondary  to  primary  affections  of  a  like  kind  to  those 
which  induce  non-scrofulous  inflammations ;  to  carious  teeth ;  to  eruptions 
about  the  ears,  and  face,  and  head;  to  stomatitis,  and  to  similar  affections. 
The  only  features  in  which  the  scrofulous  glands  at  first  differ  from  those 
which  are  not  scrofulous,  are  their  indolency,  and  the  absence  of  pain  and  of 
the  more  acute  signs  of  inflammation.  But  in  their  later  course,  the}T  devi- 
ate more  and  more  widely  from  what  may  be  regarded  as  the  natural  course 
of  inflammation  in  a  healthy  subject.  The  primary  cause  upon  which  the 
inflammation  depends,  may  disappear,  but  the  enlargement  of  the  gland 
endures;  nay,  other  and  neighboring  glands  become  enlarged.  And  in  one 
or  other  of  them,  the  solid  feel  gives  place  to  fluctuation,  the  skin  reddens, 
and  at  length  an  abscess  points  and  breaks.  Suppuration  may  occur  in  the 
inflamed  gland  or  in  the  surrounding  tissues,  excited  apparently  by  the  con- 
tiguity of  inflamed  structures.  In  either  case,  the  typical  ulcers  of  scrofula 
are  frequently  produced,  and  disfiguring  scars  may  finally  result.  Or  in 
place  of  ulcers,  sinuses  are  formed,  which  lead  directly  into  suppurating 


244  SCROFULA  AND  TUBERCLE. 

cavities  lined  with  caseous  material ;  and,  as  long  as  any  of  this  material 
remains,  the  sinuses  continue  to  discharge. 

The  scrofulous  maladies  of  bones  and  joints,  if  not  so  frequent  as  those  of 
the  lymphatic  glands,  are  not  much  less  so,  and  are  among  the  most  import- 
ant of  all  scrofulous  affections.  The  bones  are  very  liable  to  subacute  and 
chronic  inflammation,  affecting  more  often  the  periosteum  than  the  substance 
of  the  bone,  or  attacking  both  the  periosteum  and  the  bone,  and  leading,  in 
a  large  number  of  instances,  to  caries  and  necrosis.  It  is  not  uncommon  to 
find  several  bones  in  the  same  subject  thus  carious,  as  in  the  older  of  the  two 
patients  whose  cases  have  been  related.  The  bones,  too,  are  the  parts  of  the 
joints  in  which  scrofula  frequently  commences.  The  articular  ends  become 
enlarged,  and  are  slightly  hot  and  tender;  the  cancellous  tissue  is  infiltrated 
with  the  products  of  inflammation  ;  caseation  ensues  ;  the  inflammation  ex- 
tends towards  the  joint ;  the  cartilage  ulcerates,  or  is  stripped  off;  and  the 
whole  joint  becomes  inflamed.  Instead  of  the  bones,  the  synovial  membrane 
is  often  the  structure  first  attacked.  It  becomes  thickened,  though  the  fluid 
in  the  joint  may  not  be  much  increased ;  the  inflammation  slowly  extends  to 
other  structures  ;  suppuration  takes  place,  with  the  formation  of  sinuses  ;  and 
the  joint  is  at  length  destroyed.  The  "  white  swellings"  of  joints  are  in  many 
instances  scrofulous  affections,  in  which  the  disease  has  had  its  origin  in  the 
articular  extremities  of  the  bones. 

Relation  of  Scrofula  to  Tubercle. — Many  of  the  affections  thus  described 
as  scrofulous  can  only  with  difficulty  be  distinguished  clinically  from  those 
associated  with  tubercle,  and  even  when  the  diseased  structures  are  examined 
after  removal  or  death,  the  appearances  presented  by  the  two  diseases  are  so 
similar  that  the  diagnosis  can  be  made  only  by  microscopical  investigation. 
This  clinical  difficulty  has  so  long  been  recognized,  that  the  custom  has 
obtained  of  classing  both  diseases  under  the  common  term  strumous,  a  custom 
objectionable  solely  because  the  word  is  not  always  employed  in  this  clinical 
sense ;  and  some  confusion  of  terms  has  on  this  account  resulted.  The  strik- 
ing similarity  between  the  lesions  of  scrofula  and  tubercle,  has,  not  unnatu- 
rally, suggested  that  the  two  diseases  are  closely  related.  Indeed,  some 
authors  refuse  to  recognize  even  a  pathological  difference  between  them,  and 
the  fact  that  in  the  principal  works  on  surgery  and  medicine  they  are  almost 
invariably  included  in  the  same  section  or  chapter,  shows  how  largely  the 
impression  of  their  near  relationship  prevails.  Yet  it  is  not  easy  accurately 
to  define  the  tie  by  which  they  are  connected.  It  appears  almost  certain  that 
tuberculous  parents  may  beget  children  who  are  scrofulous,  and  probably 
tuberculous  children  may  be  derived  from  scrofulous  parents.  But  since 
either  disease  may  apparently  be  acquired  without  inheritance,  under  certain 
favoring  conditions,  it  is  difficult  to  prove  that  anything  more  is  inherited 
than  a,  weakly  constitution,  in  which  under  certain  conditions  scrofula  or 
tubercle  is  developed. 

It  has  become  the  fashion,  of  late  years,  for  those  who  distinguish  between 
the  two  discuses  to  regard  scrofula  as  an  affection  which  disposes  more  than 
any  other  to  tubercle,J  not  merely  by  the  general  weakness  it  induces,  but  on 
account  of  the  frequency  with  which  caseous  material  is  produced.  If  in 
this  theory  it  he  implied  that  persons  who  have  for  years  suffered  from  typical 
scrofula,  frequently  fall  victims  to  typical  tuberculosis,  I  must  confess  that  I 
have  not  often  observed  the  sequence.  But  a  different  method  is  employed 
to  prove  the  relation.     Rindfleisch,2  for  example,  holds  that  the  very  large 

1  Frankel,  Birch-Hirschfeld,  Rindfleisch,  Billroth,  etc. 

*  Ziemssen'a  Handbuch,  Bd.  v.,  Abth.  2,  S.  149.     Leipzig,  1874. 


MODIFICATIONS   PRODUCED   BY   SCROFULA   IN   OTHER   DISEASES.  245 

majority  of  tuberculous  lymphatic  glands  are  secondary,  not  to  primary 
tuberculous  affections  of  the  parts  whence  the  lymphatics  traverse  them  in 
their  course  toward  the  main  lymphatic  trunks,  hut  to  primary  scrofulous 
affections  of  these  parts.  The  scrofulous  inflammations  tend  in  most  cases  to 
caseation,  and  from  the  caseous  material  thus  produced  infection  of  tubercle 
occurs  (secondaiy  tuberculosis).  Only  one  fault  can  be  found  with  this  inge- 
nious theory,  but  unfortunately  it  is  a  grave  one:  the  diagnosis  of  the  primary 
scrofulous  affection  rests  upon  too  slender  a  base.  Because  caseation  is  a 
frequent  result  of  scrofulous  inflammation,  it  is  assumed  that  the  presence  of 
caseous  material  is  a  proof  that  a  disease  is  scrofulous — an  argument  in  a 
circle  which  cannot  be  permitted.  If  there  really  exists  a  closer  relation  than 
that  of  similarity  of  morbid  or  pathological  conditions,  it  must  I  think  be 
admitted  that  we  have  not  yet  succeeded  in  defining  it. 

Modifications  produced  by  Scrofula  in  other  Diseases. — The  affections 
significant  of  scrofula  have  been  described,  but  the  account  of  the  effects  of 
scrofula  is  only  partially  complete. 

For  (1)  we  may  believe  that  all  simple  processes  of  disease  may  be  modified 
by  scrofula.  The  epididymitis,  for  example,  which  complicates  gonorrhoea  in 
a  scrofulous  subject,  does  not  pursue  the  rapid  course  of  an  ordinary  epididy- 
mitis, and  disappear  under  treatment  in  a  few  days.  It  may  set  in  with  equal 
severity,  and  the  acute  symptoms  may  rapidly  subside ;  but  thickening  and 
induration  of  the  epididymis  remain,  with  slight  heat  and  tenderness  ;  or  the 
inflammation  may  extend  to  the  body  of  the  testis,  and,  in  spite  of  treatment, 
suppuration,  and  even  hernia  testis,  may  take  place.  So,  too,  the  primary 
affection,  the  gonorrhoea,  instead  of  passing  off  as  usual  under  appropriate 
treatment,  subsides  into  a  gleet  most  difficult  to  cure. 

And  (2)  we  know  that  the  processes  of  certain  specific  diseases  are  largely 
influenced  by  scrofula.  In  no  disease  is  this  more  marked,  perhaps,  than  in 
syphilis,  the  secondaiy  and  tertiary  manifestations  of  which  are  aggravated 
by  scrofula  in  an  extreme  degree.  As  I  write,  the  miserable  condition  of  one 
unfortunate  young  man,  the  subject  of  both  diseases,  is  present  to  my  mind. 
First  treated  in  the  hospital  for  scrofula,  one  of  the  most  characteristic 
features  of  which  was  a  white  swelling  of  one  knee,  he  was  so  indiscreet, 
when  only  partially  recovered,  as  to  expose  himself  to  the  contagion  of 
syphilis.  When  some  three  or  four  months  later  he  was  again  an  inmate  of 
the  hospital,  he  was  suffering  from  secondary  symptoms  of  the  severest  kind. 
The  profuse  eruptions  on  his  face  and  body  suppurated,  superficial  ulcers  and 
large,  foul  scabs  were  formed,  and  frightful  disfiguration  was  produced. 
Both  eyes  were  attacked  with  iritis,  which  lasted  long,  and  left  them  perma- 
nently injured.  His  tongue  and  fauces  were  extensively  and  deeply  ulcerated. 
The  glands  in  various  regions  of  the  body  became  permanently  enlarged. 
And  with  these  local  lesions  was  associated  much  greater  constitutional  dis- 
turbance than  is  usual.  And,  as  the  scrofulous  disposition  appeared  to  render 
every  manifestation  of  syphilis  more  grave,  so  the  syphilis  appeared  to  aggra- 
vate the  scrofulous  lesions;  for  the  knee,  which  had  previously  exhibited 
signs  of  improvement  so  clear  that  the  disease  seemed  nearly  at  an  end,  again 
became  actively  inflamed,  and  threatened  suppuration.  It  has  not  yet  been 
shown  that  there  is  any  relation  more  intimate  than  this  between  syphilis 
and  scrofula  or  tubercle.1  The  children  of  syphilitic  parents  are  not  more 
prone  to  these  diseases  than  other  children  whose  constitutions  are  habitually 
feeble.  !STor  does  acquired  syphilis  increase  the  liability  to  scrofula  and  tuber- 
cle, unless  by  inducing  serious  exhaustion. 

1  Bumstead  and  Taylor  ;  Venereal  Diseases,  1879,  p.  498. 


246  SCROFULA  AND  TUBERCLE. 

Another  disease  sometimes  influenced  by  scrofula  is  gout.  To  this  Sir 
James  Paget1  thus  refers  in  his  Clinical  Lectures  and  Essays:  "It  is  not  very 

rare  to  find  gout  mingled  with  scrofula The  real  mingling  of 

gout  and  scrofula  is  found  in  elderly  persons.  In  these  a  gouty  inflamma- 
tion may  drift  into  true  scrofulous  inflammation,  and  the  risk,  though  it  be 
not  great,  should  always  be  kept  in  mind."  And  further:  "I  believe  that  we 
may  hold  cases  such  as  these  to  be  due,  mainly,  to  the  coincident  inheritance 
of  both  gout  and  scrofula;  and  I  may  mention  two  other  sets  of  cases  which 
may  be  referred  to  the  same  unhappy  lot  in  life.  In  the  first,  an  acute  attack 
of  gout  is  followed,  as  any  fever  may  be,  by  some  evidence  of  scrofula.  In 
the  second,  among  the  cases  of  what  I  have  called  senile  scrofula,  some  occur 
in  old  persons  whose  tissues  have  degenerated  in  long-continued  or  almost 
constant  gout." 

Causes  and  Course  of  Scrofula.— Scrofula  occurs  chiefly  at  two  periods  of 
life;  the  limits  of  the  first  period  extending  from  about  the  third  to  the  fif- 
teenth year,  while  the  second  period  scarcely  commences  before  the  age  of 
sixty.  But  though  it  is  most  common  in  childhood  and  old  age,  no  time  of 
life  is  free  from  its  occurrence.  It  attacks  persons  in  every  rank  of  life,  spar- 
ing neither  male  nor  female,  rich  nor  poor;  but  the  children  of  the  poor  are 
so  much  more  liable  to  scrofula  than  the  children  of  the  rich  or  comfortable 
classes,  that  poverty  is  justly  regarded  as,  at  least,  a  predisposing  cause  of 
scrofula,  on  account  of  the  indifferent  and  insufficient  food,  the  foul  and  heavy 
air,  the  scanty  clothing,  constant  exposure  to  wet  and  cold,  and  the  hundred 
other  evils  with  which  it  is  associated.  But  the  most  powerful  cause  of 
scrofula  is  universally  admitted  to  be  inheritance,  the  inheritance  of  a  predis- 
position to  the  disease ;  for  it  does  not  appear  that  children  are  ever  born  suf- 
fering from  scrofula.  It  may  probably  be  inherited  either  from  parents  who 
are  scrofulous,  or  from  those  who  are  tuberculous ;  and  the  predisposition  may 
be  so  strong  as  to  amount  almost  to  preordination,  when,  for  example,  the 
disease  is  not  averted  even  by  the  most  ample  and  ably  directed  means. 

Some  children  who  are  born  thus  predisposed  to  scrofula,  are  said  to  present 
certain  general  features  of  character  and  form  which  are  significant  of  the 
disease.  The  dark  type  of  strumous  subject  so  frequently  described,  is  per- 
haps more  often  met  with  than  any  other,  but  the  cases  related  above  show 
that  the  disease  is  not  confined  to  the  individuals  of  any  type  or  types.  On 
the  other  hand,  the  features  of  the  individual  are  liable  to  be  seriously  modi- 
fied by  scrofula.  The  upper  lip  may  become  large  and  tumid,  the  face  coarse, 
the  eyelids  red  and  swollen  from  repeated  attacks  of  inflammation;  so  that 
scrofula  may  often  be  easily  recognized  by  the  changes  it  has  thus  induced. 
Even  the  anaemia  so  frequently  observed  in  scrofulous  subjects,  is  said  by 
Birch-Tlirschleld2  to  be  a  result  and  not  a  precursor  of  the  disease,  which 
occurs  as  often  in  those  who  are  full-blooded  and  in  whom  the  normal  ratio 
of  the  two  forms  of  blood-corpuscles  is  preserved. 

Prognosis  of  Scrofula. — The  manifestations  of  scrofula  are  the  same  at  all 
periods  <>f  life,  and  similar  tissues  and  organs  are  liable  to  be  attacked.  But 
while  there  is  said  to  be  a  natural  tendency  towards  recovery  in  .young  sub- 
jects,aged  persona  and  oubtedly  grow  worse,  not  better.  The  prognosis  depends, 
however,  not  tnerely  on  the  age  of  the  individual,  but  on  the  parts  which  are 
affected.  Affections  of  the  skin  and  mucous  membrane,  for  example,  may 
exist  for  many  years  with  scarcely  an  appreciable  effect  upon  the  general 

1  Clinical  Lectures  and  Essays,  2il  ed.,  p.  3nrt. 

2  Ziemssen's  Cyclopaedia,  vol.  xvi.     English  translation,  London,  1877. 


TREATMENT    OF   SCROFULA.  247 

health;  but  suppuration  in  connection  with  large  bones  and  joints  is  peculiarly 
fatal,  on  account  of  the  diseases  which  it  may  induce,  such  as  hectic  fever  and 
amyloid  degeneration. 

Treatment  of  Scrofula. — Fortunately,  scrofula  at  all  ages  and  in  all  its 
phases,  is  fairly  amenable  to  treatment.  The  disposition,  which  is  inherited, 
cannot  perhaps  be  eradicated,  but  most  of  the  lesions  may  by  appropriate 
means  be  much  improved,  if,  indeed,  they  cannot  be  completely  eared.  The 
treatment  must  be  both  general  and  local,  for  many  affections  which  resist 
either  form  of  treatment  alone,  will  yield  to  the  combined  influence  of  both. 
The  chief  obstacle  to  successful  constitutional  treatment  is  the  lack  of  ample 
means  to  carry  out  what  is  most  desirable.  For  as  the  children  of  the  poor 
furnish  by  far  the  most  numerous  body  of  patients,  chiefly  by  reason  of  their 
poverty,  so  one  of  the  main  difficulties  in  treatment  is  the  continual  struggle 
with  poverty.  The  parents  are  recommended  to  clothe  their  children  warmly, 
to  feed  them  on  plain  but  good  and  nourishing  diet,  to  place  them  where  they 
may  drink  the  purest  water  and  breathe  the  finest  air,  to  preserve  them  from 
frequent  wet  and  cold,  or  send  them  where  they  may  enjoy  the  advantages  of 
sea-air  and  warm  sea-baths — advice  for  the  most  part  admirable,  but  as  im- 
practicable as  admirable,  for  all  these  things  are  far  beyond  the  reach  of  the 
poorest  classes. 

By  the  establishment,  in  large  towns,  of  hospitals  especially  devoted  to  cer- 
tain scrofulous  affections,  an  attempt  has  been  made  to  supply  the  food, 
warmth,  and  attention,  which  poor  people  cannot  obtain  at  home ;  and  by  the 
foundation  of  country  convalescent  homes,  something  has  been  done  to  allevi- 
ate the  sufferings  of  the  scrofulous  poor.  But  in  the  large  cities  of  the  old 
world,  scrofula  in  various  forms  abounds,  and  the  good  which  is  accomplished 
by  charitable  institutions  produces  scarcely  an  appreciable  effect  upon  a  mass 
of  misery  so  vast.  It  has  been  suggested  that  the  air  of  hospitals  is  injurious 
to  scrofulous  patients,  particularly  where  numerous  suppurating  wounds  are 
treated.  But  while  it  may  certainly  be  admitted  that  country  patients  are 
not  likely  to  derive  benefit  from  a  prolonged  residence  in  the  hospital  of  a 
large  city,  there  can  be  just  as  little  doubt  that  the  poor  dwellers  in  large 
cities  often  owe  their  lives  to  the  cleanliness  with  which  their  scrofulous  sores 
are  treated  in  hospitals,  and  to  the  food  and  medicines  which  they  there 
receive.1 

!N"ot  only  are  food  and  air  and  clothing  useful,  but  certain  medicines  enjoy 
a  well-merited  reputation  for  their  efficacy  against  scrofula.  Of  these,  cod- 
liver  oil  is  probably  the  most  valuable,  administered  either  alone  or  in  com- 
bination with  other  remedies.  It  should  be  given  once  or  twice  a  day,  in 
doses  varying  from  one  to  two  or  three  fluidraehms,  quickly  after  the  taking 
of  a  meal,  when  it  is  least  likely  to  produce  gastric  disturbance.  Its  use 
may  be  continued  during  many  weeks  or  months,  but  it  is  better  at  intervals 
to  leave  it  off.  It  may,  for  example,  be  drunk  every  day  for  fourteen  days, 
and  then  remitted  for  a  week;  by  this  means  the  indigestion  and  nausea  it  is 
liable  to  produce  may  be  avoided.  It  can  scarcely  ever  be  tolerated  in  the 
summer,  but  fortunately  is  not  then  so  necessary  as  during  the  cold  season. 
In  the  summer  too  it  quickly  becomes  rancid  unless  kept  in  a  perfectly  cool 
place,  and  on  this  account  is  not  a  suitable  medicine  for  out-patients  (luring 
the  hot  season  of  the  year.  Children  speedily  learn  not  merely  to  tolerate, 
but  even  to  like  the  oil,  and  will  often  take  it  greedily,  especially  when  cer- 

1  With  regard  to  the  advantages  of  sea-air  and  'warm  sea-haths,  there  exists  at  present  some 
difference  of  opinion.  It  has,  for  instance,  lately  heen  asserted  that  on  scrofulous  affections  of 
the  eye,  the  effect  of  sea-air  is  positively  prejudicial,  and  that  inflammations  of  lymphatic  glands 
and  hones  remain  stationary  at  seaside  places.     (Birch-Hirschfeld,  loc.  cit.) 


248  SCROFULA  AND  TUBERCLE. 

tain  syrups  are  mingled  with  it;  and  many  adults  acquire  a  certain  taste  for 
it,  or  at  least  cease  after  a  while  to  regard  it  with  disgust.  In  cases,  however, 
in  which  the  distaste  is  so  great  that  it  cannot  or  will  not  be  overcome,  cod- 
liver  oil  may  be  given  in  a  peculiarly  refined  form,  that,  for  instance,  of  the 
'perfected  cod-liver  oil,  or  in  combination  with  certain  preparations  which  almost 
completely  deprive  it  of  its  obnoxious  qualities,  such  for  example  as  maltine. 
Next  in  value  to  cod-liver  oil  are  the  preparations  of  iron,  the  syrups  of  the 
iodide  or  the  phosphates,  administered  either  alone  or  in  combination  with 
the  oil.  They  are  indicated  where  anaemia  is  a  prominent  feature  of  the  dis- 
ease, and  may  in  all  cases  be  employed  in  the  intervals  between  the  adminis- 
tration of  oil,  or  during  the  summer. 

It  need  scarcely  be  remarked  that  when  other  diseases  are  associated  with 
scrofula,  the  remedies  which  are  employed  should  be  such  as  are  appropriate 
for  their  treatment  as  well  as  for  that  of  the  scrofula  itself.  Thus,  when 
syphilis  is  acquired  by  a  scrofulous  subject,  the  milder  preparations  of  mer- 
cury, such  as  the  bichloride,  may  be  exhibited  together  with  iron  and  cod- 
liver  oil ;  and  iodide  of  potassium  may  be  given  with  iodide  of  iron  with  the 
Oest  result. 

The  local  treatment  of  scrofulous  affections  is  exceedingly  important,  although 
in  most  of  them  the  same  general  principles  are  involved  as  in  the  treatment 
of  non-scrofulous  affections  of  the  same  structures.  The  rest  which  is  essen- 
tial for  most  joint-inflammations,  is  quite  as  essential  for  joint-inflammations 
which  are  scrofulous.  But  if  rest  can  be  obtained  by  the  aid  of  some  appa- 
ratus which  does  not  necessitate  rest  for  the  whole  body,  a  great  advantage 
will  generally  be  gained.  Operations  are  performed  for  the  removal  of 
necrosed  or  carious  bone,  equally  whether  the  patient  is  scrofulous  or  not, 
although  in  the  former  case  the  prospect  of  cure  of  the  disease  by  operation 
is  greatly  lessened.  Many  cases  of  scrofulous  caries  are,  however,  better  not 
treated  by  operation.  Of  such  are  the  swollen  and  "  blowm-out"  phalanges, 
of  which  the  fore-finger  of  the  old  woman  furnished  an  example.  They 
occur  frequently  in  children;  sinuses  forming,  through  which  soft,  carious 
bone,  or  a  soft  pulp  in  which  lie  grits  of  bone,  may  be  distinguished.  The 
temptation  is  strong  to  interfere,  to  cut  through  the  thin  shell  of  bone  and 
clear  out  the  cavity  within.  But  the  usual  effect  of  operation  appears  to  be 
to  light  up  fresh  inflammation,  or  to  leave  wounds  which  will  not  heal;  while 
the  original  disease,  had  it  been  left  to  itself  with  a  strip  of  lint  or  other 
covering  around  the  finger,  would  have  almost  surely  healed  with  less  delay — 
with  shortening  of  the  finger,  no  doubt,  and  with  puckered  scars,  but  with 
less  deformity  'than  after  operation.  Carious  patches  of  the  bones  of  old 
people  who  are  scrofulous,  should  be  operated  on  only  with  the  greatest  cau- 
tion, if  at  all.  For  the  parts  are  apt  to  resent  the  injury  of  an  operation,  and 
the  wounds  inflicted  show  no  tendency  to  heal.  Of  scrofula  in  the  aged,  it 
may  be  generally  stated  that  the  ordinary  specific  remedies,  local  and  con- 
st it'nfional,  are  much  less  efficient  than  when  employed  for  younger  persons, 
and  that  good  food,  warmth,  and  rest,  are,  in  such  patients,  more  than  ever 
necessary  for  Its  treatment.1 

Scrofulous  abscesses,  if  they  are  not  very  large,  may  be  opened  in  the  usual 
manner;  but  the  extensive  'cold  abscesses  of  the  pelvis  and  abdomen,  gene- 
rally associated  with  diseased  bones  or  joints,  should  be  left  to  point  and 
break;  or  if  they  will  not  do  so,  but  slowly  burrow  between  the  structures  of 
the  thigh  or  buttock,  should  be  evacuated  with  every  antiseptic  precaution. 
Small  abscesses  about  the  neck  and  face  may  often  he  treated  with  thehap- 
piest  result  by  aspiration.     Even  when  matter  is  pointing,  and  the  skin  so 

1  Sir  James  Paget,  loc.  cit.,  p.  344. 


TREATMENT    OF    SCROFULA. 


249 


thin  and  red  that  it  seems  as  if  it  must  give  way,  breaking  may  often  he  pre- 
vented by  thrusting  an  aspirator-tube  through  the  normal  tissues  at  some 
distance  from  the  abscess,  into  its  cavity,  and  drawing  off  the  pus.  The  gen- 
tle pressure  of  a  pad  and  bandage  will  prevent  refilling.  By  this  means  not 
only  is  tedious  suppuration  avoided,  but  no  appreciable  scar  remains. 

Scrofulous  ulcers  are  often  very  difficult  to  treat  successfully.  They  com- 
monly recpiire  stimulation,  and  frequent  change  of  stimulation.  One  of  the 
best  applications  is  finely-powdered  iodoform,  not  pure,  but  mixed  with 
thrice  its  bulk  of  oxide  of  zinc  or  starch.  The  ulcer  should  be  cleansed  and 
dried,  dusted  over  with  the  powder,  and  covered  with  a  piece  of  soft  rag  or 
lint.  Nitric  oxide  ointment  of  mercury  [Unguent,  hydrarg.  oxidi  rubri], 
black  wash,  and  other  similar  applications,  may  also  lie  advantageously  em- 
ployed. But  when  the  progress  of  an  ulcer  is  very  tedious,  and  its  edges  are 
undermined,  I  have  often  seen  a  marvellous  improvement  produced  by  freely 
cutting  away  the  edges  to  the  surrounding  healthy  tissues.  The  area  of  the 
ulcer  is  by  this  means  widely  extended,  but  healing  generally  rapidly  ensues, 
and  the  remaining  scar  is  far  less  unsightly  than  that  which  might  be  ex- 
pected from  the  healing  of  the  ulcer  as  it  existed  before  the  operation. 

The  treatment  of  enlargement  of  the  glands  is  most  unsatisfactory.  The 
apparent  cause  of  the  enlargement  may  be  removed,  and  the  health  improved 
by  various  constitutional  measures,  but  the  glands  remain  enlarged,  or  vary 
in  size  from  time  to  time.  No  local  treatment  appears  decidedly  to  influence 
their  course.  The  action  of  counter-irritants  is  so  uncertain  that,  although 
they  are  used,  they  often  do  more  harm  than  good,  appearing  to  excite  rather 
than  allay  the  unhealthy  processes.  The  question  of  removal  of  such 
glands  is  scarcely  more  settled  than  the  question  of  removal  of  tuberculous 
glands.  Where  only  one  or  two  glands  are  enlarged,  and  the  enlargement 
has  existed  for  many  months  or  years,  operation  may  be  practised  with  suc- 
cess; but  the  danger  is  ever  present  that  the  wound  may  heal  indifferently, 
and  be  a  source  of  more  distress  than  the  disease  for  which  it  was  inflicted. 
The  obstinate  sores  and  sinuses  connected  with  caseous  cavities  in  glands, 
may  best  be  treated,  not  by  excision  of  the  glands,  but  by  opening  up  the 
wounds,  and  scraping  carefully  away  the  caseous  material  with  a  silver  spoon 
or  scraper. 

Lastly,  it  is  sometimes  advisable  that  the  unsightly  scars  left  by  old  scrofu- 
lous sores  should  be  treated.  More  than  once  I  have  been  applied  to  by 
young  women,  otherwise  well-looking,  whose  necks  were  disfigured  by  nu- 
merous scars,  the  remains  of  scrofula  in  childhood.  Thus  prevented  from 
obtaining  good  situations  as  servants  or  governesses,  they  are  urgent  for  an 
operation.  Nor  is  there  any  sufficient  reason  wh}7,  if  all  active  signs  of  scro- 
fula have  long  ceased  to  exist,  an  operation  should  not  be  practised.  The  m<  »st 
prominent  ridges  may  with  advantage  be  removed,  and  deeply  indented  scars 
be  raised  by  the  operation  recommended  by  Mr.  Adams.1 

1  Observations  on  Contraction  of  the  Fingers,  ....  also  on  the  Obliteration  of  Depressed 
Cicatrices,  etc.     London,  1879. 


RACHITIS. 


BY 


J.  LEWIS  SMITH,  M.T). 


CLINICAL  PROFESSOR  OF  DISEASES  OF  CHILDREN   IN   THE  BELLEVUE  HOSPITAL  MEDICAL  COLLEGE, 

NEW  YORK. 


Rachitis,  or  rickets,  is,  in  the  plan  of  this  work,  considered  as  a  constitu- 
tional disease,  but  it  would  seem  in  some  respects  equally  in  consonance  with 
observed  facts,  to  regard  it  as  a  disease  of  the  osseous  system,  in  which,  in 
certain  cases,  other  systems  are  secondarily  affected.  It  occurs  in  the  first 
years  of  life,  and,  therefore,  during  the  period  of  most  active  growth  of  the 
skeleton.  It  is  characterized  by  an  abnormal  nutrition  and  changed  physio- 
logical action  of  the  bone-producing  tissues,  namely  the  epiphyseal  cartilage 
and  the  periosteum,  and  by  the  arrest,  more  or  less  complete,  of  the  deposi- 
tion of  lime  salts  in  these  tissues. 


Frequency  of  Rachitis. 

Rachitis  is  a  common  result  of  faulty  diet  and  of  anti-hygienic  conditions, 
and  is,  therefore,  frequent  among  the  poor  of  cities,  and  especially  in  fami- 
lies who  dwell  in  crowded  tenement  houses.  It  has,  heretofore,  been  pre- 
valent in  the  city  infantile  asylums,  but  of  late  years,  as  regards  at  least  the 
city  of  New  York,  it  is  much  less  common,  in  consequence  of  the  greater 
attention  now  given  to  sanitary  requirements  in  the  management  of  these 
institutions.  Mild  cases  of  rickets  are  often  overlooked,  since  physicians  may 
not  be  summoned  to  attend  them,  while  even  if  they  be  summoned,  many, 
who  have  not  given  particular  attention  to  this  disease,  are  apt  to  err  in 
diagnosis,  and  to  refer  the  symptoms  to  some  other  than  the  true  cause. 
Commencing  gradually  and  insidiously,  rachitis  not  infrequently  continues 
for  months,  even  in  its  typical  form,  before  a  correct  diagnosis  is  made.  In 
the  absence  of  deformity,  which  is  a  late  symptom,  the  fretfulness,  tender- 
ness of  surface,  and  perspirations,  receive  a  wrong  explanation.  Practitioners 
who  have  heretofore  given  little  attention  to  this  malady,  and  who  believe  it 
to  be  rare,  if  they  are  instructed  in  reference  to  its  characteristic  signs,  and 
look  for  them  in  their  visits  among  the  city  poor,  are  surprised  at  the  num- 
ber of  cases  with  which  they  meet.  A  few  years  since,  in  the  Xew  York 
Infant  Asylum,  my  attention  was  directed  to  a  rachitic  child,  whose  head  had 
so  changed  from  the  normal  shape  that  the  nurses,  as  well  as  the  physician, 
had  remarked  the  difference.  Prompted  by  the  occurrence  of  this  case,  which 
had  gradually  developed  under  my  eyes,  I  made  a  careful  examination  of  all 
the  infants,  and  discovered,  what  I  had  not  previously  suspected,  that  about 
one  in  every  nine  had  become  rachitic.  In  most  of  the  infants  the  disease 
was  mild,  but  with  symptoms  so  characteristic  that  it  was  readily  recognized. 
By  effecting  certain  improvements  in  the  diet,  among  which  was  the  daily 

(251) 


252  RACHITIS. 

allowance  of  beef-tea  to  the  older  infants,  rachitis,  unless  of  a  mild  type,  has 
since  been  rare  in  this  institution. 

The  late  Dr.  John  S.  Parry,  of  Philadelphia,  stated  that  at  least  twenty- 
eight  per  cent,  of  all  the  children,  between  the  ages  of  one  month  and  five 
years,  who  came  under  his  observation  in  the  Philadelphia  Hospital  during 
the  three  years  preceding  the  publication  of  his  paper,  in  1872,  were  rachitic. 
This  is  certainly  a  larger  proportion  of  those  who  present  indubitably  ra- 
chitic symptoms  than  occurs  in  any  of  the  three,  New  York  institutions  for 
children  with  which  I  have  an  official  connection.  In  the  New  York 
Foundling  Asylum,  with  its  sixteen  hundred  inmates,  and  in  the  Bureau  for 
the  Relief  of  the  Out-door  Poor,  where  over  eight  thousand  children  are 
annually  treated,  rachitis  is  certainly  less  frequent  than  is  indicated  by  the 
statistics  of  Dr.  Parry.  In  Europe,  from  the  testimony  of  many  observers, 
both  continental  and  British,  rickets  is  very  common  among  the  families  who 
seek  medical  advice  in  institutions  of  charity.  Ritter  von  Rittershain  finds 
that  thirty-one  per  cent,  of  all  the  children  who  are  brought  to  the  Prague 
Medical  "  Poliklinik,"  are  rachitic,  and  Prof.  Henoch  states  that  the  propor- 
tion is  equally  large  in  the  families  of  Berlin,  who  are  in  similar  reduced 
circumstances.  According  to  Dr.  Gee,  whose  statement  was,  however,  made 
as  far  back  as  1867-68,  of  the  patients  under  the  age  of  two  years,  in  the 
London  Hospital  for  Sick  Children,  30.3  per  cent,  are  rachitic.  Both  Dr. 
Hillier  and  Sir  Wm.  Jenner  not  only  allude  to  the  frequency  of  rachitis,  but 
state  that  it  is  the  cause  of  many  deaths  in  London  families.  It  appears, 
therefore,  that  this  malady,  though  not  rare  in  the  American  cities  where 
ill-fed  and  ill-housed  families  congregate,  is  less  prevalent  than  in  families 
similarly  situated  in  Europe.  The  greater  immunity  in  this  country  must 
be  due  to  other  causes  besides  difference  in  nationality,  for  the  poor  of  the 
American  cities  are  largely  of  foreign  birth. 

But  rachitis  does  not  occur  exclusively  among  the  poor.  Children  of  well- 
to-do  families  are  also  liable  to  it,  provided  that  the  conditions  soon  to  be 
enumerated  are  present.  Ignorance  or  disregard  of  the  hygienic  requirements 
of  young  children,  and  especially  the  use  of  improper  diet,  leads  to  the  de- 
velopment of  rachitis  in  wealthy  as  well  as  in  destitute  families.  Merei,  in 
his  treatise  on  the  Disorders  of  Infantile  Development  (London,  1855),  states 
that  in  Manchester,  where  his  observations  were  made,  one  child  in  every 
five,  in  families  in  comfortable  circumstances,  presented  rachitic  symptoms; 
and  he  believes  that  this  cannot  be  much  above  the  real  proportion  in  "the 
whole  of  the  wealthy  classes." 

Rachitis,  in  its  milder  form,  is  not  uncommon  in  affluent  families  in  this 
country,  the  cause  of  the  delayed  dentition,  fretfulness,  and  perspiration,  not 
being  suspected  in  many  instances,  as  I  have  had  opportunities  to  observe. 
(  M'tcn  family  physicians  are  not  consulted  in  reference  to  such  symptoms,  and 
when  they  are  called  in,  so  little  attention  has  rachitis  received  on  the  part  of 
many  practitioners,  that  they  arc  very  apt  to  overlook  the  true  pathological 
state  which  is  present.  Still,  admitting  the  fact  that  many  cases  are  not 
diagnosticated,  I  repeat  that,  though  rachitis  is  not  uncommon  on  this  side 
of  the  Atlantic,  its  percentage  of  frequency  falls  below  that  "observed  in  Eu- 
ropean cities,  a  fact  which  may  be  due  to  less  crowding  in  their  domiciles, 
and  to  a  more  liberal  and  better  supply  of  food  among  the  families  of  the 
poor  in  this  country. 

Age  at  which  Rachitis  Occurs. 

Rachitis  is,  with  few  exceptions,  a  disease  of  infancy,  commencing  prior 
to  the  age  of  two  and  a  halt'  years.     Now  and  then,  it,  or  a  state  closely  re- 


AGE   AT   WHICH   RACHITIS   OCCURS. 


253 


Fig.  9. 


sembling  it,  occurs  in  the  foetal  state,  causing  deformities,  such  as  are  present 
in  typical  cases.  In  the  Ivinderspital  Museum,  at  Prague,  is  a  specimen 
showing  this,  and  described  by  Hitter.  Ilink  and  Winkler  also  describe  such 
cases,  and  Virehow  alludes  to  a  specimen  in  the  Wurzburg 
Museum,  which  exhibits  such  deformities  as  characterize 
rachitis.  Bednar  even  regards  foetal  rachitis  as  not  uncom- 
mon (Hillier,  Parry).  In  the  "Wood  Museum  of  Bellevue 
Hospital,  is  a  skeleton  which  is  probably  similar  to  those 
in  the  Prague  and  Wurzburg  Museums.  It  shows  in  a 
striking  maimer  the  deformities  of  this  congenital  disease. 
The  case  occurred  in  my  practice,  and  the  dissection  was 
made  by  Prof.  Francis  Delafield.  The  infant,  born  at  term, 
died  a  few  hours  after  birth  from  atelectasis,  apparently 
produced  by  the  contracted  state  of.  the  thoracic  walls. 
The  parents  were  hard  working  English  people,  whose 
mode  of  life  and  surroundings  were  such  as  are  known  to 
conduce  to  rachitis.  They  were  free  from  syphilitic  taint. 
The  accompanying  wood-cut  (Fig.  9)  represents  this  skeleton. 
The  following  remarkable  case  of  supposed  foetal  rachitis 
was  related  to  me  by  Heitzmann,  whose  interesting  experi- 
ments will  be  presently  detailed  : — ■ 

A  woman  who  had  frequently  inhaled  the  vapor  of  lactic  acid, 
each  day,  for  many  months,  as  she  was  employed  to  feed  animals 
with  this  agent,  gave  birth  to  an  infant,  at  term,  which  died  imme- 
diately after  it  was  born.      It  exhibited  the  signs  of  congenital 
rachitis  in  a  high  degree.     The  skull  bones  were  completely  absent; 
in  the  cartilages  of  the  bones  of  the  extremities,  and  in  those  of 
the  ribs,  there  were  scanty  depositions  of  lime  salts,  and  numerous 
infractions.     The  death  of  the  child   was  evidently  due  to  the  absence  of  the   skull 
bones,  inasmuch  as  the  pressure  of  the  womb  during  delivery  had  caused  cerebral  hem- 
orrhage.    All  the  organs  of  the  chest  and  abdomen  were  found  in  full  development  and 
healthy. 

We  will  see,  hereafter,  that  the  theory  which  attributes  rachitis,  in  certain 
instances,  to  a  chemical  irritant,  is  proved  by  experiment,  and  that  it  has 
already  been  shown  that  two  such  agents,  phosphorus  and  lactic  acid,  may 
cause  this  disease.  Now,  as  the  irritating  action  of  phosphorus  on  the  osse- 
ous system  occurs  when  it  is  inhaled  in  the  form  of  vapor,  as  well  as  when 
received  in  the  ingesta,  so  lactic  acid,  if  the  above  case  be  rightly  interpreted, 
produces  its  special  effect  upon  the  bone-producing  tissues  when  inhaled,  as 
decidedly  as  when  received  in  the  ingesta  or  generated  in  the  system.  These 
remarks  seem  necessary  for  an  understanding  of  this  unusual  case,  although 
they  anticipate  what  will  be  said  under  the  head  of  etiology.  In  the  New 
York  Journal  of  Obstetrics  for  November,  1870,  Prof.  Abraham  Jacobi  also  pub- 
lished the  description  of  a  case  of  congenital  rachitic  craniotabes.  Whether 
or  not  we  accept  as  genuine  all  the  reported  cases  of  foetal  rachitis,  there  can 
be  little  doubt,  from  the  number  of  observations  already  made  and  carefully 
recorded,  and  from  the  opinion  of  high  authorities  like  Virehow,  that  such 
cases  do  occur. 

Enlargement  of  the  costo-chondral  articulations,  known  as  the  "  rachitic 
rosary,"  which  is  one  of  the  earliest  and  most  reliable  signs  of  rickets,  has 
been^  observed,  though  rarely,  in  infants  only  a  few  weeks  old.  Dr.  Parry 
saw  it  as  early  as  the  sixth  week  after  birth,1  and  Dr.  Gee  at  the  third  or 


Skeleton  of  a  rachitic 
infant,  which  died  a  few 
hours  after  birth. 


American  Journal  of  the  Medical  Sciences,  January,  IS* 


254  RACHITIS. 

fourth  week.1  This  should  not,  however,  he  regarded  as  a  sign  of  rachitis, 
unless  the  enlargement  be  so  great  that  it  can  be  readily  appreciated  by  ex- 
amination through  the  integument,  or  by  sight,  for  in  young  children,  with 
the  bones  in  the  process  of  normal  development,  these  joints  usually  have  a 
diameter  a  little  larger  than  that  of  the  ribs.  Rachitis,  with  few  exceptions, 
begins  within  the  first  eighteen  months  of  life.  Though  first  detected  and 
diagnosticated  at  a  later  date,  it  will  ordinarily  be  ascertained,  on  inquiry, 
that  its  symptoms  had  an  earlier  beginning.  Still,  according  to  certain  ob- 
servers, it  may  have  a  considerably  later  commencement,  Glisson,  Portal, 
and  Tripier  state  that  they  have  seen  it  commence  in  children  who  were  well 
on  towards  the  age  of  puberty.  Sir  Wm.  Jenner  states  that  he  has  seen 
children  of  seven  "and  eight  years,  who  were  only  beginning  to  suffer  from 
rachitis.2 

The  following  are   the  aggregate   statistics  of  Bruennische,  von   Rittershain,   and 
Ritsche,  relating  to  the  age  at  which  rachitis  occurs : — 

No.  of  Cases. 

During  the  first  half  year,            .......  99 

"           "    second  half  of  first  year,            .....  259 

"           "         "      year, 342 

"           "    third  year, 134 

"           "    fourth  year,       ........  31 

"           "    fifth  year, 17 

Between  the  fifth  and  ninth  years,       ......  21 

Aggregate, 903 


Causes  of  Rachitis. 

Inheritance. — In  some  infants  there  is  an  undoubted  hereditary  predispo- 
sition to  rachitis.  Feeble  digestion  and  defective  assimilation  in  the  infant, 
which  are,  as  we  shall  see,  important  factors  in  producing  the  rachitic  state,  are 
often  traceable  to  disease  or  cachexia  of  one  or  both  parents.  The  offspring 
of  a  tubercular,  syphilitic,  or  otherwise  enfeebled  parent,  is  more  likely  to 
become  rachitic  than  those  of  healthy  and  robust  ancestry ;  and  it  appears 
that  disease  of  the  mother  is  more  apt  to  entail  a  rachitic  predisposition 
than  that  of  the  father.  Among  the  parental  causes  may  be  mentioned 
poverty,  hardships,  and  defective  nutrition  of  either  parent ;  age  of  the  father, 
and  exhausting  discharges  of  the  mother,  such  as  purulent,  hemorrhoidal,  or 
uterine  fluxes. 

Food. — Of  the  exciting  causes,  the  most  common  is  the  use  of  food  not 
sufficiently  nutritive,  or,  if  nutritious,  not  suited  to  the  age  and  digestive 
powers  of  the  child.  Thin  and  poor  breast  milk,  and  artificial  food  of  poor 
quality,  or  not  suitable  for  the  stage  of  growth  and  development,  are  common 
causes  of  rickets.  Those  children  who  have  been  prematurely  weaned,  and 
who  have  been  given  a  food  which  is  not  a  proper  substitute  for  the  natural 
aliment,  and  those  too  long  wet-nursed  and  not  allowed  the  additional  aliment 
which  they  require,  are  especially  liable  to  this  disease.  Those  whose  di- 
gestive power  is  feeble,  from  whatever  cause,  are  more  apt  to  become  rachitic 
than  those  who,  in  a  state  of  robust  health,  have  a  hearty  digestion.  Hence 
we  meet  with  rickets  as  a  sequel  of  various  protracted  and  exhausting  mala- 
dies during  infancy. 

1  St.  Bartholomew's  Hospital  Reports,  vol.  iv. 
8    Lancet,  December  11,  1880. 


ARTIFICIAL   PRODUCTION   OF   RACHITIS.  255 

It  might  be  supposed,  from  the  nature  of  rachitis,  that  the  use  of  food  de- 
ficient in  phosphoric  acid  and  lime  was  the  common  cause  of  rachitis;  but 
facts  show  that  this  is  not  the  correct  view  of  its  etiology,  as  it  commonly 
occurs,  although  in  its  treatment  these  agents  are  of  undoubted  value.  The 
disturbed  and  altered  nutrition  of  the  osteo-plastic  tissues,  namely  of  the  epi- 
physeal cartilage  and  the  periosteum,  is  the  important  factor  in  producing 
the  rachitic  bone  disease,  and  this  may  occur  although  the  ingesta  contain  a 
sufficient  amount  of  phosphoric  acid  and  lime.  Deficiency  of  these  substances 
probably  tends  to  diminish  the  amount  of  lime  deposition,  but  is  not  the 
essential  element  in  the  causation  of  the  malady.  This  is  to  be  found  in  the 
unhealthy  condition  and  action  of  the  cartilage  and  periosteum,  or  rather  in 
the  agencies,  now  partly  ascertained,  which  produce  the  abnormal  state  and 
altered  nutrition  of  these  tissues. 


Artificial  Production  of  Rachitis. 

The  important  fact  has  been  ascertained  by  experiments  on  young  animals, 
that  rachitis  can  be  produced,  as  I  have  already  stated,  by  at  least  two  chemi- 
cal agents,  which  may  be  admitted  into  the  system  in  the  ingesta,  and  which 
exert  an  especially  irritating  action  on  the  osteo-plastic  tissues.  Senator  states, 
in  Ziemssen's  Encyclopaedia,  that  "Wegner  .  .  .  has  recently  brought 
experimental  evidence  to  show  that  true  rickets  may  be  artificially  produced 
by  the  continued  administration  of  very  minute  doses  of  phosphorus  .  .  . 
together  with  a  simultaneous  withdrawal  of  lime  from  the  food."  The  fact 
being  established  that  it  is  possible  to  produce  rickets  by  certain  deleterious 
principles  in  the  ingesta,  opens  an  interesting  field  for  experimental  inquiry. 
Since  improper  feeding  and  indigestion  are  known  to  sustain  a  causative  rela- 
tion to  rachitis,  experiments  have  been  made  to  ascertain  whether  some 
chemical  agent,  developed  in  the  system  during  the  digestive  process,  or  intro- 
duced with  the  food,  may  not  cause  rachitis  as  it  ordinarily  occurs  in  the 
infant.  Among  the  foremost  in  that  line  of  experiment  has  been  Dr.  Ileitz- 
mann,  a  resident  of  Vienna  when  his  observations  were  made,  but  now  a  citi- 
zen of  ^ew  York. 

In  young  children,  acids,  especially  the  lactic,  are  commonly  produced,  and 
often  in  lftrge  quantities,  as  the  result  of  improper  feeding,  of  indigestion,  and 
of  intestinal  catarrh.  The  acidity  of  the  infant's  stools,  under  such  conditions 
of  ill  health,  is  well  known.  What  more  natural,  then,  than  the  supposition 
or  belief  that  this  acid,  thus  generated,  sustains  the  same  causative  relation 
to  rickets,  as  phosphorus  in  the  experiments  which  have  been  made  with 
that  agent.  But  the  acid  which  is  produced  so  abundantly  in  disturbed 
states  of  the  digestive  apparatus  in  the  infant,  believed  to  be  chiefly  the  lac- 
tic, must,  in  order  to  reach  the  bones  and  influence  their  nutrition,  pass 
through  the  blood,  which  is  always  alkaline.  This  difficulty  in  the  way  of 
the  theory  that  lactic  acid  is  the  irritating  agent,  is  removed  by  plivsiolojists 
who  tell  us  that  among  the  organic  acids  the  existence  of  lactic  acid  in  healthy 
blood  is  not  entirely  beyond  doubt,  but  that  it  has  been  found  in  the  latter 
under  abnormal  conditions.1  Lactic  acid  has  also  been  found,  after  having 
made  the  circuit  of  the  system,  in  the  excretion  from  the  kidneys. 

Ileitzmann,  in  order  to  ascertain  whether  this  acid  sustained  a  causative 
'relation  to  rickets,  made  a  series  of  experiments,  which  have  passed  into  the 
literature  of  this  disease,  and  he  has  kindly  furnished  me  with  their  details, 
as  follows: — 

'  Heinrich  Frey,  of  Zurich. 


256  RACHITIS. 

Marchand,  Ragsky,  Lehman,  Simon,  and  others  have  found  free  lactic  acid  in  the 
urine  of  persons  suffering  from  rickets  and  osteo-malaeia.  C.  Schmidt  discovered  lac- 
tic acid  in  the  liquid  of  malacic  shaft-bones,  which  were  transformed  into  globular  cysts. 
Encouraged  by  these  chemical  researches,  I  undertook  a  series  of  experiments  on  the 
action  of  lactic  acid,  administered  both  by  the  mouth  and  by  subcutaneous  injection, 
upon  the  bones  of  living  animals,  which  experiments  were  begun  in  April,  1872,  and 
continued  until  the  end  of  October,  1873.  The  experiments  were  made  upon  five  dogs, 
seven  cats,  two  rabbits,  and  one  squirrel.  On  dogs  and  cats  under  one  year  of  age, 
the  lactic  acid,  given  either  by  mouth  or  injection,  in  combination  with  restricted  ad- 
ministration of  calcareous  food,  produced  swelling  of  the  epiphyses  of  the  shaft  bones 
and  of  the  anterior  ends  of  the  ribs,  at  their  attachments  to  the  costal  cartilages.  This 
result  was  plain  in  the  second  week  after  the  beginning  of  the  lactic  acid  treatment. 
Up  to  the  fourth  and  fifth  weeks,  the  swelling  of  the  epiphyses  and  of  the  ends  of  the 
ribs  kept  increasing,  and  then  was  accompanied  by  curvatures  of  the  bones  of  the  ex- 
tremities. As  accompanying  symptoms,  I  noticed  catarrhal  inflammation  of  the  con- 
junctiva, of  the  mucosa  of  the  bronchi,  the  stomach,  and  the  intestines,  with  emaciation 
and  convulsive  movements  of  the  extremities.  The  microscopic  examination  of  the 
epiphyses  gave  an  image  fully  identical  with  that  of  the  epiphyses  of  rickety  children. 
Upon  continuing  the  administration  of  the  lactic  acid,  the  SAvelling  of  the  epiphyses  of 
the  shaft  bones  gradually  increased,  and  so  did  the  curvatures  of  the  shaft  bones.  Af- 
ter four  or  five  months  of  lactic  acid  treatment,  under  often  repeated  catarrhal  inflam- 
mations of  the  above  named  mucous  layers,  the  shaft  bones  became  soft  to  such  a  degree 
that  they  could  be  bent  like  the  branches  of  a  willow-tree.  After  from  four  to  eleven 
months  of  the  same  treatment,  the  microscopic  examination  of  the  bones  gave  a  result 
corresponding  with  that  obtained  from  the  bones  of  women  who  have  died  with  osteo- 
malacia. 

On  the  three  herbivorous  animals  no  swelling  of  the  epiphyses  was  noticeable.  One 
rabbit  died  three  months  and  the  other  five  months  after  the  commencement  of  admin- 
istration of  the  lactic  acid,  but  with  symptoms  of  inanition.  No  marked  evidences  of 
rachitis  or  malacia  were  traceable  in  the  bones  of  these  animals.  The  squirrel,  on  the 
contrary,  which  died  after  thirteen  months  of  treatment  with  lactic  acid,  gave  all  the 
features  of  osteo-malacia. 

My  experiments  (jive  the  result  that  by  continuous  administration  of  lactic  acid,  at 
frst  rickets,  and  afterwards  osteo-malacia,  can  be  artificially  produced  in  flesh-eaters  ; 
while  in  herbivorous  animals,  osteo-malacia  sets  in  without  preceding  symptoms  of 
rickets.  Through  these  experiments  I  have  proved  the  identity  in  nature  of  these  two 
diseases,  the  differences  in  their  course  being  due  to  the  difference  in  the  age  at  which 
the  solution  of  the  lime  salts  is  established.  .  .  Rickets  can  be  produced  on  dogs 
and  cats  only  under  the  age  of  ten  or  twelve  months.  Mr.  Hess  fed  with  lactic  acid  a 
dog  of  the  age  of  one  and  a  half  years,  and  failed  to  produce  rickets.  This  result  is  in 
full  agreement  with  my  experiments.  1  maintain  that  lactic  acid,  though  not  free  in 
the  blood,  if  in  contact  with  the  tissues  producing  bone,  or  with  fully  developed  bone, 
owing  to  its  great  affinity  for  lime,  either  prevents  the  formation  of  bone  (rickets),  or 
dissolves  ready-made  bone  (osteo-malacia). 

On  the  other  hand,  rachitis  sometimes  occurs  in  infants  who  present  no 
history  of  indigestion  or  of  intestinal  catarrh,  and  in  whom  there  is  no  ground 
for  the  belief  mat  lactic  or  any  other  acid  is  produced  in  undue  or  injurious 
quantity.  In  a  considerable  proportion  of  such  eases,  inquiry  elicits  the  fact 
of  anti-hygienic  conditions,  hut  there  is  no  evidence  of  imperfect  digestion, 
or  of  gastro-intestina]  catarrh,  such  as  produces  lactic  acid.  In  the  cases  oc- 
curring in  the  Now  York  Infant  Asylum,  alluded  to  above,  some  of  the  chil- 
dren had  manifest  gastro-intestina]  derangement;  but  others,  who  were  wet- 
nursed,  gave  no  evidence  of  faulty  digestion,  though  the  nutriment  which 
they  received  was  probably  insufficient;  for,  as  already  stated,  by  providing 
a  more  liberal  diet,  by  allowing  among  other  articles  the  juice  of  meat,  rachitis 
became  much  less  frequent,  and  is  seldom  observed  at  present  among  the  in- 
fants of  that  institution,  unless  in  a  very  mild  form. 

Vircnow  and  others  have  suggested  that  the  prime  factor  in  causing  rachitis 


ANATOMICAL    CHARACTERS   OF   RACHITIS.  257 

is  the  use  of  a  diet  that  is  deficient  in  calcareous  salts,  and  we  have  seen  that 
in  the  interesting  experiments  of  Dr.  Heitzmann,  the  administration  of  cal- 
careous food  to  the  animals  was  restricted.  Still,  as  Xiemeyer  has  well  said, 
deprivation  or  restricted  use  of  the  chalky  salts  cannot  possibly  cause  the 
most  important  histological  change  in  rachitis,  namely,  the  proliferation  of 
the  epiphyseal  cartilages  and  periosteum,  and  we  must  look  tor  some  other 
factor  in  the  causation. 

Pathology  furnishes  many  examples  of  chronic  disease  attended  by  pro- 
liferation of  tissue,  the  causes  of  which  are  not  uniform.  Cirrhosis,  with  its 
proliferation  of  hepatic  connective  tissue,  which,  as  we  shall  see,  presents  a 
similitude  in  some  respects  to  rachitis,  is  sometimes  undoubtedly  produced 
by  the  irritating  action  of  a  chemical  agent,  to  wit,  alcohol ;  but  all  physi- 
cians know  that  there  are  many  cirrhotic  patients  who  refrain  entirely  from 
the  use  of  alcohol  in  any  form.  In  like  maimer,  it  seems  to  me  that,  if  we 
admit,  as  we  must  in  the  light  of  experiments,  that  certain  chemical  agents, 
notably  phosphorus  and  lactic  acid,  introduced  into  the  system  or  produced 
in  it,  cause  rachitis  by  their  irritating  action,  there  are  other  typical  cases  in 
which  there  is  no  reason  to  suspect  the  operation  of  such  agents.  "We  must, 
therefore,  remain  in  the  belief  that  rachitis,  like  many  other  pathological 
processes,  does  not  result  from  a  fixed  and  uniform  cause,  but  from  conditions 
which  vary  to  a  certain  extent  in  different  patients. 


Anatomical  Characters  op  Rachitis. 

For  convenience  of  description,  the  course  of  rachitis  is  divided  into  three 
periods :  (1)  That  of  proliferation  and  altered  nutrition  of  cartilage  and  peri- 
osteum ;  (2)  That  of  curvature  and  deformity ;  (3)  That  of  reconstruction. 

Anatomical  Characters  in  the  Stage  of  Proliferation  and  Altered 
Nutrition. — Ossification  of  a  long  bone  occurs  from  the  epiphyseal  cartilages, 
and  from  the  periosteal  or  fibrous  membrane  which  surrounds,  nourishes,  and 
protects  the  bone.  Growth  in  length  is  from  the  former,  in  thickness  from 
the  latter.  As  regards  the  flat  bone,  while  growth  in  thickness  occurs  from 
the  periosteum,  that  in  breadth  is  from  the  cartilage  of  its  border,  which  cor- 
responds with  the  epiphyseal  cartilage  of  the  long  bone. 

Cartilaginous  Changes. — If  we  examine  the  epiphyseal  cartilage  of  a  long 
bone  during  normal  ossification,  we  observe,  first  beginning  at  the  distal  end, 
a  white  zone,  consisting  of  the  hyaline  matrix,  in  which  are  the  usual  carti- 
lage cells.  This  constitutes  most  of  the  cartilage.  Underneath  this,  and 
nearer  the  bone,  is  the  zone  of  proliferation,  the  "cartilage  in  which  is- softer 
and  more  yielding  than  that  of  the  distal  zone,  in  consequence  of  cell  forma- 
tion, and  absorption  of  the  matrix  to  make  way  for  cell-groups.  Each  car- 
tilage cell  in  the  proliferating  zone  has  divided  into  two  cells,  and  each  of 
these  cells  into  two  other  cells,  and  the  division  has  been  repeated  so  that 
eight  cells  instead  of  one  are  observed,  surrounded  by  a  common  capsule. 
The  capsule  becomes  distended  by  the  cell  multiplication,  and  by  the  swelling 
of  each  cell,  the  size  of  which  is  considerably  greater  than  that  of  the  parent 
cell.  Near  the  bone,  namely,  along  the  extremity  of  the  diaphysis,  the  cell- 
groups,  inclosed  in  their  capsules,  nearly  touch  each  other,  the  matrix  having, 
for  the  most  part,  been  absorbed.  The  end  of  the  diaphysis  is  covered  with 
a  layer  of  these  cell-groups,  about  to  undergo  ossification,  with  almost  no 
intervening  matrix.  The  proliferating  zone  lias  very  little  depth.  It  appears 
vol.  i. — 17 


258  RACHITIS. 

to  the  naked  eye  as  a  very  thin,  scarcely  perceptible  layer  of  a  reddish-gray 
color  upon  the  end  of  the  shaft.  It  is  so  shallow  that  it  does  not  perceptibly 
increase  the  thickness  of  the  cartilage. 

In  rachitis,  the  state  of  affairs  is  different.  The  zone  of  proliferation,  in- 
stead of  being  confined  to  a  single,  or  at  most  double,  layer  of  cell-groups,  con- 
sists of  many  layers  involving  nearly  the  whole  epiph}Tseal  cartilage.  The 
cells,  still  inclosed  in  their  distended  capsules,  undergo  a  more  frequent 
division  than  in  health,  so  that  instead  of  groups  of  eight  cells,  as  in  the 
normal  state,  each  group  consists  of  from  thirty  to  forty  cells.  Therefore, 
in  rachitis,  the  proliferating  cartilaginous  zone  is  a  broad  cushion,  very  soft, 
of  a  grayish  translucent  appearance,  causing  the  characteristic  swelling  ob- 
served around  the  joint.  Over  the  distal  end  of  the  proliferating  cartilage, 
there  may  still  be  a  layer  or  zone,  though  perhaps  of  little  depth,  of  normal 
cartilage,  like  that  in  health. 

Osseous  Changes. — While  this  occurs,  the  ossifying  process  is  also  arrested. 
"We  indeed  perceive  an  effort  in  the  direction  of  bone  formation.  The  Haver- 
sian canals,  surrounded  by  capillary  loops,  extend  from  the  bone  into  the  pro- 
liferating zone  of  cartilage.  Their  extension  is  effected  by  absorption  of  the 
matrix  and  appropriation  of  cell-groups  which  lie  in  their  way.  The  cells 
in  these  groups,  as  they  enter  the  Haversian  system,  become  much  smaller  by 
a  rapid  segmentation,  forming  medullary  cells.  We  also  find,  as  further  evi- 
dence of  the  attempt  at  bone-formation,  granules  and  masses  of  lime  scat- 
tered through  the  cartilage,  and  here  and  there  spiculse  and  nodules  of  true 
bone,  springing  up  from  the  bony  substratum  of  the  shaft.  Some  of  the 
canals  extend  far  into  the  cartilage,  nearly  indeed  to  its  free  surface,  but  most 
of  them  terminate  in  its  lowest  portion.  The  growth  of  bone  in  thickness 
occurs  from  the  under  surface  of  the  periosteum.  In  health,  a  soft,  vascular, 
germinal  tissue  springs  from  the  periosteal  surface,  and  rapidly  receives 
lime  salts,  and  is  transformed  into  bone.  This  germinal  tissue,  consisting 
largely  of  capillaries  rising  from  the  fibrous  tissue  of  the  periosteum,  is  a 
very  thin  substratum,  barely  visible,  transient,  and  constantly  changing  from 
its  conversion  into  bone. 

In  rachitis,  this  vascular  sub-periosteal  tissue,  not  undergoing,  or  under- 
going slowly  and  imperfectly,  the  osseous  transformation,  and  at  the  same 
time  increasing  more  rapidly  than  in  health,  under  the  irritating  influence  of 
the  rachitic  disease  becomes  a  thick  layer.  Its  color  and  appearance  are  like 
spleen  pulp,  so  that  the  older  observers  supposed  that  there  was  a  hemorrhagic 
extravasation  between  the  periosteum  and  the  bone.  There  is,  however,  no 
extravasation  of  blood,  unless  it  accidentally  occur  from  the  numerous  delicate 
capillaries.  The  resemblance  to  extravasated  blood,  or  spleen  pulp,  is  due  to 
the  abundant  growth  of  large  and  thin-walled  capillaries  from  the  under  sur- 
face of  the  pen<  >steum,  as  shown  by  the  microscope.  This  vaseular  outgrowth 
is,  for  the  most  part,  quite  uniform  over  the  diaphysis  of  the  long  bones, 
while  upon  the  cranial  bones  its  thickness  is  much  greater  in  one  locality  than 
in  another.  The  attempt  at  ossification  also  appears  in  this  tissue.  Lime 
salts  are  scantily  and  loosely  deposited  through  it,  forming  osteophytes — 
vascular  and  fragile — rather  than  true  bone. 

The  question  naturally  arises:  how  does  rachitis  affect  bone  which  is 
already  formed  when  the  rachitic  state  begins?  Virchow's  answer  is  the 
following:  "Rachitis  has  ...  by  more  accurate  investigation  been 
shown  t.o  consist,  not  in  a  process  of  softening  in  the  old  bone,  as  it  had  pre- 
viously I"1''!!  considered  to  be, but  in  a  non-solidification  of  the  fresh  layers  as 
they  form;  the  old  layers  being  consumed  by  the  normally  progressive  forma- 
tion of  medullary  cavities,  and  the  new  remaining  soft,  the  bone  becomes 


ANATOMICAL  CHARACTERS  OF  RACHITIS. 


259 


brittle."1  It  seems,  however,  from  the  experiments  of  Heitzmann,  that  this 
opinion  should  be  modified,  at  least  as  regards  rachitis  produced  by  lactic 
acid.  Moreover,  in  rachitic  cranio-tabes,  occurring  in  infancy,  there  is 
certainly  bone  absorption,  for  portions  of  the  occipital  and  parietal  bones  are 
absorbed  to  cause  the  soft  spaces.  We  must,  therefore,  believe  that  there  is  in 
rachitis  more  or  less  absorption  of  lime  salts  in  the  bone,  in  addition  to  that 
required  in  the  normal  growth  of  medullary  cavities  and  canals  for  vessels. 

In  healthy  bone,  the  earthy  salts  are  in  excess  of  organic  matter,  nearly  in 
the  proportion  of  two  to  one ;  but  in  rachitis  the  proportion  is  reversed,  the 
organic  matter  being  much  in  excess.  The  following  table  gives  analyses  of 
rachitic  bones  by  Marehand,  Davy,  Boettger,  and  Friedleben : — 


Femur. 

Ei 

dins. 

Vertebra 

Inorganic. 

Organic. 

Inorganic. 

Organic. 

Inorganic.             Organic. 

Case 

I. 

II. 

III. 

IV. 

20.60 
37.80 
20.89 
52.85 

79.40 

62.20  (conval.) 

79.11 

47.15 

21.24 
20.00 

78.76 
80.00 

IS. 68              81.32 
32.29               67.71 

As  might  be  expected,  the  relative  proportion  of  organic  and  inorganic 
matter  Araries  greatly  in  different  cases,  and  at  different  stages  of  the  same 
case.  In  severe  rachitis  many  bones  are  affected.  It  is  stated  that  there  is 
no  bone  in  the  entire  skeleton  that  may  not  suffer,  but  in  mild  cases  only  a 
few  are  involved,  at  least  to  such  an  extent  as  to  produce  structural  changes, 
appreciable  to  touch  or  sight. 

Pathology  of  Rachitis. — In  this  connection,  it  is  proper  to  consider  the  pa- 
thology of  rachitis.  What  is  its  nature?.  Niemeyer  in  my  opinion  expresses 
the  correct  view,  when  he  says  "it  seems  to  me  that  the  most  probable  hy- 
pothesis regarding  the  cause  of  rachitis  is  that  which  refers  it  to  inflammation 
of  the  epiphyseal  cartilages  and  periosteum."  The  increased  vascularity  of 
the  periosteum,  the  proliferation  of  periosteum  and  cartilage,  the  tenderness 
and  pain  on  motion,  and  the  febrile  movement  in  acute  forms  of  the  disease, 
indicate  inflammation  rather  than  any  other  recognized  pathological  state. 
The  rachitic  inflammation  as  it  affects  the  osseous  system,  appears  to  be  of  a 
chronic  or  subacute  character,  presenting  an  analogy  with  certain  other  well- 
known  inflammations,  such  as  cirrhosis  and  certain  forms  of  chronic  ne- 
phritis, in  which  proliferation  of  connective  tissue  and  sclerosis  occur.  The 
eburnation  rather  than  normal  ossification,  which  terminates  the  rachitic 
process,  may  properly  be  considered  an  osteo-sclerosis.  Conformably  with 
the  theory  of  the  inflammatory  nature  of  rachitis,  the  periosteum  is  found 
infiltrated  and  thickened,  and  of  a  reddish  hue  from  hyperemia,  and  from 
the  presence  of  the  newly-formed  capillaries  underneath,  which  have  been 
described  above  as  forming  a  layer  of  considerable  thickness,  known  as  the 
"germinal,  vascular  tissue."  Moreover,  as  in  inflammations,  a  secretion  or 
exudation  occurs  over  the  bone  from  the  under  surface  of  the  periosteum  ;  it 
has  a  reddish,  gelatinous-looking  appearance.  The  various  interspaces  in 
long,  short,  and  flat  bones,  the  diploe,  cancelli,  and  inter-lamellar  openings, 
contain  a  substance  similar  to  that  exuded  under  the  periosteum,  resembling, 
says  Trousseau,  "red,  pale  gooseberry  jam."  It  appears,  like  that  under  the 
periosteum,  to  be  an  inflammatory  exudation. 

1  Cellular  Pathology,  Chance's  Translation,  Lecture  xix. 


260  RACHITIS. 

Anatomical  Characters  in  the  Stage  of  Deformity. — Rachitic  bone,  when 
the  disease  has  continued  for  some  time  and  is  still  in  its  active  period,  presents 
a  bluish  or  dusky-red  appearance,  from  its  increased  vascularity.  After  a 
variable  time,  weeks  or  months  according  to  the  severity  of  the  disease,  de- 
formities begin  to  appear. 

Spiegelberg's  description  of  the  appearance  of  the  rachitic  foetus  corresponds 
for  the  most"  part  with  what  I  observed  in  the  one  whose  skeleton  is  repre- 
sented in  Fig.  9.  According  to  this  writer,  the  body  and  limbs  are  plump: 
the  latter  short  and  curved  ;  the  abdomen  large  and  prominent ;  and  the  head 
sometimes  hydrocephalic.  The  skin  is  thick  and  loose,  and  the  adipose  tissue 
well  developed ;  the  liver  large ;  the  epiphyses  swollen  and  soft;  the  short 
and  curved  diaphyses  sometimes  broken.  The  rotundity  of  the  thorax  is 
preserved,  and  the  sternum  is  not  carried  forward,  since  there  has  been  no 
respiration  ;  the  ribs,  in  softness  and  liability  to  fracture,  correspond  with 
the  long  bones  of  the  extremities.  The  sternum,  most  of  all  the  bones,  shows 
the  delay  in  ossification ;  the  clavicle  is  among  those  least  affected.  The 
cranium  may  be  represented  by  a  membranous  bag  with  plaques  of  bone,  or 
the  cranial  bones  may  be  formed  and  in  shape,  but  thickened  and  softened  ; 
the  sacral  promontory  is  pressed  forward  and  downward  ;  the  sacral  vertebrae 
flattened;  the  ilia  flattened  and  widened  ;  and  the  pubic  arch  increased. 

It  is  interesting  to  compare  these  deformities  with  those  in  the  child,  since 
they  occur  under  conditions  so  very  different.  Eachitic  bone  seldom  retains 
its  normal  form  or  shape ;  its  projecting  points  are  rounded,  and,  as  soon  as 
it  softens,  it  begins  to  yield  to  pressure  exerted  upon  it.  Hence  the  curva- 
tures, so  common  and  characteristic.  The  portion  of  a  long  bone  which  is 
formed  after  rachitis  commences,  contains  so  little  earthy  matter  that  it  bends 
readily  in  its  fresh  state,  either  by  muscular  action  or  by  the  weight  of  the 
trunk,  "in  the  manner,"  says  Vogel,  "of  a  quill  or  willow  stick."  The  in- 
terior of  the  bone,  which  was  formed  before  rachitis  began,  and  which  con- 
tains nearly  or  quite  the  normal  proportion  of  lime,  is  apt  to  break  instead 
of  bending,  but,  as  it  is  surrounded  on  all  sides  by  the  soft  tissue,  the  frag- 
ments are  not  displaced,  and  probably  do  not  crepitate.  So  scanty  is  the 
calcareous  deposition  in  typical  cases,  that,  says  Trousseau,  "  the  bones  .  . 
.  .  can  be  cut  with  a  knife  with  as  much  ease  as  a  carrot  or  other  soft 
root,"  and  the  dried  specimen  weighs  but  from  one-sixth  to  one-eighth  as 
much  as  normal  bone.  One  writer  states  that  the  dried  rachitic  bone  is 
sometimes  so  porous,  from  the  small  amount  of  lime  which  it  contains,  that 
it  is  possible  to  respire  through  it,  as  through  a  sponge. 

In  ordinary  cases,  the  bones  which  exhibit  most  strikingly  the  rachitic 
change,  and  which,  therefore,  should  be  carefully  examined  in  making  the 
diagnosis,  are  the  cranial  bones,  the  ribs,  and  the  radius- — the  sternal  ends  of 
the  former,  and  the  lower  end  of  the  latter.  It  is  seldom  that  these  bones  do 
n<.t  give  evidence  of  the  disease,  if  it  be  present,  and  in  greater  degree  than 
other  bones.  They  are  the  first  to  be  affected  to  an  extent  that  is  appreciable 
to  the  observer. 

Changes  hi  the  Cranial  Bones. — Tn  these  bones  interesting  and  important 
alterations  occur.  Their  edges,  which  correspond  with  the  epiphyseal  carti- 
lages,  undergo  proliferation,  and  become  thickened  like  the  latter.  This 
thickening,  and  the  delayed  union  of  the  sutures,  produce  grooves,  which  can 
be  traced  by  the  fingers  between  the  bones,  and  which  are  sometimes  appre- 
ciable to  the  sight.  Rachitis  causes  sonic  enlargement  of  the  cranium,  but  the 
enlargement  seems  greater  than  it  really  is,  on  account  of  the  retarded  growth 
of  the  facial  hones.      In  a  discussion  on  rachitis  in  the  London  Pathological 


ANATOMICAL    CHARACTERS    OF    RACHITIS.  261 

Society,  reported  in  the  Lancet,'  it  was  stated  that  in  seventeen  rachitic  chil- 
dren, with  an  average  age  of  4.72  years,  the  average  circumference  of  the 
head  was  21.22  inches,  while  in  the  same  number  who  were  non-rachitic,  and 
with  an  average  age  of  6.05  years,  the  average  circumference  was  19.95  inches. 

The  retarded  ossification  is  manifested  not  only  in  the  open  sutures,  but 
also  in  the  large  size  and  patency  of  the  fontanelles,  which  are  not  closed  till 
long  after  the  usual  time.  The  anterior  fontanelle  should  be  closed  between 
the  fifteenth  and  twentieth  months,  but,  in  the  rachitic,  it  remains  membra- 
nous till  after  the  second  year,  even  into  the  third  or  fourth  year.  Since  ex- 
amination of  the  anterior  fontanelle  is  important  in  determining  whether  or 
not  rachitis  be  present,  it  should  be  borne  in  mind  that,  in  the  normal  state, 
this  space  increases  in  size  till  the  seventh  month,  when  it  is  at  its  maximum, 
and  that  after  the  ninth  month  it  becomes  progressively  smaller. 

The  shape  of  the  rachitic  head  varies.  In  general,  instead  of  its  normal 
rounded  form,  it  approaches  a  square  shape.  Another  type  is  sometimes  ob- 
served in  which  there  is  no  marked  angularity,  but  in  which  the  anteropos- 
terior diameter  is  enlarged.  In  the  square  head,  the  forehead  projects,  and 
both  the  frontal  and  parietal  protuberances  are  unusually  prominent.  The. 
sutures  are  depressed  to  a  certain  extent,  as  has  already  been  mentioned,  and 
the  anterior,  lateral,  superior,  and  posterior  surfaces  of  the  cranium  are  more 
flattened  than  in  health.  The  lambdoidal  suture,  which  should  close  by  the 
fourth  month,  and  the  sagittal,  which  should  close  by  the  end  of  the  first 
year,  have  made  little  progress  towards  union  when  the  second  year  begins. 
The  undue  prominence  of  the  frontal  and  parietal  bosses  takes  its  origin  from 
the  exaggerated  proliferation  of  the  periosteal  or  fibrous  covering  of  the 
bones. 

Craniotabes. — Thinning  of  the  cranial  bones  in  places,  so  that  the  brain 
lacks  proper  protection,  has  long  been  noticed  in  the  examination  of  rachitic 
heads,  but  the  injury  that  results  to  the  infant  was  overlooked  till  pointed 
out  by  Dr.  Elsasser.  Craniotabes  occurs  for  the  most  part  in  patients  under 
the  age  of  one  year,  and  a  large  proportion  are  under  eight  months.  Its 
occurrence  in  the  foetus,  as  shown  by  a  case  published  in  the  New  York  Ob- 
stetrical Journal  in  1870,  and  by  Heitzinann's  case,  has  already  been  alluded 
to.  The  factors  in  producing  this  thinning  are  rachitic  softening  of  the  bones 
and  pressure;  pressure  of  the  brain  from  within  and  of  the  pillow  from  without. 
Consequently,  the  portions  of  the  cranial  arch  in  which  the  thinning  occurs 
are  the  posterior  and  lateral,  the  occipital  bone  and  the  posterior  half  of  the 
parietal.  If  the  infant  lie  chiefly  on  one  side,  in  its  crib,  on  this  side  the 
craniotabes  occurs,  while  those  portions  of  the  cranium  which  are  not  pressed 
upon,  as  the  frontal  bone,  exhibit  no  thinning.  (The  soft  spots  are  yielding 
when  pressed  upon,  and  in  the  cadaver  they  are  seen  to  be  translucent  when 
held  to  the  light.  The  amount  of  absorption  varies  greatly  according  to 
the  degree  of  rachitic  softening,  and  the  amount  and  continuance  of  the 
pressure.  There  may  be  in  some  instances  simple  depressions,  like  erosions 
in  the  bone,  with  a  continuous  but  thin  bony  layer  remaining,  but  in  other 
cases,  such  as  have  been  particularly  examined  and  studied  by  physicians,  the 
bone  absorption  is  complete  over  areas  of  greater  or  less  extent,  so  that  the 
pericranium  and  dura  mater  are  in  contact.  In  examining  a  child  for  cranio- 
tabes, it  should  be  borne  in  mind  that  the  margins  of  the  bones,  even  when 
there  is  no  thinning,  but  thickening  from  the  cartilaginous  proliferation,  are 
flexible  in  the  rachitic.  The  pressure  must  be  made  in  a  direction  away  from 
the  sutures,  to  ascertain  whether  craniotabes  has  occurred.      The  pressure 

>  Lancet,  1880,  vol.  ii.  p.  1017. 


262  RACHITIS. 

should  at  first  be  made  lightly  and  cautiously,  with  the  fingers,  for  if  there 
be  total  absence  of  bone,  unless  of  very  little  extent,  deep  and  forcible 
pressure  might  injure  the  brain,  for  so  soft  and  delicate  an  organ,  covered 
only  by  the  scalp  and  dura  mater,  badly  tolerates  pressure.  If  the  first  ex- 
amination detect  no  soft  place,  the  fingers  may  be  pressed  more  firmly  against 
the  scalp,  when,  if  the  bone  be  much  thinned,  so  that  there  is  only  a  small 
layer  of  the  lime  salts  underneath,  it  will  be  found  to  yield.  The  sensation 
communicated  to  the  fingers,  when  there  is  an  open  space  in  the  cranium,  and 
the  dura  mater  and  seal})  are  in  contact,  has  been  likened  to  that  experienced 
when  pressing  upon  a  fully  distended  bladder.  At  a  meeting  of  the  London 
Pathological  Society,  reported  in  the  Lancet  for  November  20, 1880,  Dr.  Lees 
presented  statistics  to  show  that  craniotabes  was  one  of  the  lesions  of  inherited 
syphilis;  but  whether  it  may  result  from  syphilis  or  not,  the  evidence  that 
there  is  a  cranial  softening  which  is  strictly  rachitic,  appears,  from  repeated 
observations,  to  be  sufficient. 

Symptoms  of  Craniotabes. — As  craniotabes  gives  rise  to  peculiar  symptoms 
quite  distinct  from  those  of  the  general  rachitic  disease,  they  may  be  pro- 
perly considered  in  this  connection.  Craniotabes  usually  occurs  during  the 
first  year  of  infancy,  and  most  frequently  prior  to  the  tenth  month.  The 
brain  at  this  age  is  soft  and  yielding,  since  it  contains  a  large  percentage  of 
water.  Unless  handled  with  care,  at  an  autopsy,  it  is  readily  lacerated,  and 
moderate  pressure  upon  it  is  seen  to  disturb  and  move  it  at  a  considerable 
distance  from  the  point  of  contact.  It  assists  to  a  proper  understanding  of 
the  symptoms  of  craniotabes  to  recall  to  mind  the  fact,  well  known  to  sur- 
geons, that  slight  depression  of  even  a  small  portion  of  the  skull  is  apt  to 
produce  grave  symptoms.  It  is  not  surprising,  therefore,  that  craniotabes 
when  there  is  a  space  of  considerable  size  in  the  cranial  arch,  destitute  of 
bone,  is  attended  by  symptoms  due  to  the  mechanical  effect  of  external  pres- 
sure, whenever  a  substance  less  yielding  than  the  brain  comes  in  contact  with 
the  unprotected  part. 

Since  pressure  from  the  pillow  without,  and  from  the  brain  within,  is  be- 
lieved to  be  the  cause  of  the  absorption,  the  craniotabes  must  obviously  occur 
in  the  posterior  and  postero-lateral  portions  of  the  cranium.  Corresponding 
with  this  explanation  of  the  causation,  the  thinning  actually  occurs  in  the 
occipital  and  posterior  portions  of  the  parietal  bones,  while  the  anterior  halves 
of  the  parietal  bones,  and  the  frontal  bones,  are  even  thicker  than  normal, 
from  the  cartilaginous  and  periosteal  proliferation  occurring  along  the  sutures 
and  on  the  surface  of  these  bones,  as  already  described.  It  is  well  known 
that  long-continued  pressure  produces  absorption  of  calcareous  matter  even 
more  readily  than  of  soft  tissues,  as  is  shown  in  the  absorption  of  a  tooth  of 
the  first  set  by  the  growth  of  the  dental  pulp  of  the  second  set.  In  the  nor- 
mal growth  of  the"  skull,  constant  absorption  of  the  under  surface  of  the 
cranial  bones  is  going  on  to  make  room  for  the  enlarging  brain,  and  when  no 
calcareous  deposition  occurs  upon  the  external  surface  to  compensate  for  the 
loss  within,  we  might  expect  even  a  greater  amount  of  craniotabes  than  ordi- 
narily occurs. 

Every  rachitic  infanl  is  fretful,  but  one  with  craniotabes  is  especially  so,  if 
the  open  spaces  be  of  considerable  size.  If  it  lie  upon  the  pillow,  in  its  ac- 
cu8tomed  manner,and  as  is  most  natural  for  it,  the  unprotected  portion  of  the 
brain  may  be  so  pressed  upon  by  the  weight  of  the  head,  that  it  feels  uncom- 
fortable. "  It  does  not  have  quiet  sleep,  probably  because  the  cerebral  circula- 
tion and  functions  are  in  a  measure  disturbed;  it  is  apt  to  awaken  readily 
and  often,  and  frets  till  it  is  taken  in  the  nurse's  arms.  Sometimes  it  in- 
stinctively seeks  a  position  on  the  edge  of  the  pillow,  with  the  face  down- 
wards, and  it  becomes  more  quiet  when  resting  over  the  nurse's  shoulder  with 


ANATOMICAL    CHARACTERS    OF    RACHITIS. 


263 


the  face  backward.  But  if  fretfulness,  disturbed  sleep,  and  the  necessity  of 
closer  attention  on  the  part  of  mother  and  nurse  were  the  only  ill  effects  of 
craniotabes,  it  would  possess  much  less  pathological  significance  than  pertains 
to  it.  Pressure  upon  so  delicate  and  important  an  organ  as  the  brain,  involves 
risks  and  produces  serious  symptoms  in  proportion  to  its  degree.  Even  a 
slight  injury  of  the  skull  which  produces  depression,  though  it  may  be 
of  trifling  amount,  will  cause  serious  forms  of  nervous  disorder.  So  cra- 
niotabes is  believed  to  sustain  a  causative  relation  in  certain  cases  to  one  of 
the  most  dangerous  of  the  neuroses,  namely  laryngismus  stridulus,  an  affec- 
tion which  is  also  designated  "internal  convulsions,"  "spasm  of  the  glottis," 
and  "  Kopp's  asthma,'  although  Kopp  was  not  the  first  to  describe  and 
recognize  the  malady.  The  etiology  of  this  neurosis  has  not  been  fully  elu- 
cidated. It  is  certain  that  a  large  proportion  of  those  who  suffer  from  it  are 
rachitic,  and  that  it  is  more  common  and  severe  where  rachitis  is  prevalent, 
as  in  England,  than  where  it  is  rare,  as  in  the  rural  districts  of  America.  It 
is  not  often  the  cause  of  death  in  this  country,  and  the  fatal  cases  that  do 
occur  are  only  seen  in  cities,  whereas  in  parts  of  Europe,  where  rachitis  is 
much  more  common  than  with  us,  it  causes  many  deaths. 

Certain  infants,  when  in  a  state  of  excitement,  have  what  are  termed 
"holding-breath  spells."  The  face  is  flushed,  and  breathing  ceases  for  some 
seconds,  after  which  respiration  returns  and  is  normal.  These  attacks  are 
unimportant,  but  they  appear  to  be  the  same  in  nature  with  the  more  severe 
and  dangerous  seizures  of  laryngismus  stridulus.  They  have  no  pathological 
significance,  excepting  as  they  show  the  same  neuropathic  state  as  that  in 
laryngismus,  and  as  they  may  be  precursors  of  this  disease.  Laryngismus 
stridulus,  or  glottic  spasm,  is  usually  preceded  by  more  or  less  impairment  of 
the  general  health,  and  often  by  fretfulness,  which  is  characteristic  of  the 
rachitic  state;  but  the  attack  occurs  suddenly,  without  premonition,  and  is 
of  short  duration.  It  begins  with  an  arrest  of  respiration,  a  true  apncea,  as  if 
from  paralysis  of  the  respiratory  centre  in  the  medulla.  The  lips  may  be  livid ; 
a  pallor  spreads  over  the  face ;  sometimes  more  or  less  rigidity  of  the  limbs 
occurs,  with  carpo-pedal  contractions,  and  after  a  few  seconds,  a  quarter  or  a 
half  minute,  a  long  and  deep  but  difficult  inspiration  through  the  narrow  chink 
of  the  glottis  follows,  accompanied  in  many  patients  by  a  whistling  or  crowing 
sound,  and  the  attack  ends  with,  per- 
haps, a  momentary  look  of  bewilder- 
ment or  dread  upon  the  child's  face. 
Now  this  disease,  like  eclampsia,  does 
not  have  a  uniform  causation.  In 
certain  cases,  it  appears  to  be  a  reflex 
phenomenon,  due  to  an  irritant  in 
some  part  of  the  system,  as  in  the 
intestines ;  but  many  observations 
have  established  the  fact  that  ra- 
chitis, also,  sustains  a  causative  rela- 
tion to  it.  A  large  proportion  of 
the  infants,  affected  with  laryngis- 
mus, exhibit  unmistakable  rachitic 
signs,  and,  in  the  opinion  of  many 
experienced  observers,  the  exposed 
state  of  the  brain  affords  explana- 
tion of  the  fact  that  so  many  of  the 
rachitic  have  this  neurosis.  Still, 
from    observations    which    I    have 

made,  and    from    tllOSe    Of   Other    Ob-       Head  of  a  rachitic  child  in  the  New  York  Infant  Asylum 


Fig.  10. 


264 


RACHITIS. 


Fig.  11. 


servers,  like  Senator,  it  is  certain  that  laryngismus  stridulus  is  common  in  the 
rachitic  who  do  not  have  craniotabes,  so  that  there  must  be  a  causative  rela- 
tion in  rachitis  to  laryngismus  independently  of  the  cranial  softening.  The 
preceding  wood-cut  represents  the  rachitic  head  of  a  child  in  the  New  York 
Infant  Asylum.     This  patient  had  also  attacks  of  laryngismus  stridulus. 

Changes  in  the  Vertebra,  etc. — The  short  bones  which  participate  in  the 
rachitic  disease,  become  softer  and  more  yielding,  and  their  cancelli  are  tilled 
with  a  reddish  pulpy  substance.  In  many  rachitic  cases,  the  vertebrae  are 
but  slightly  involved,  so  that  no  deformity  of  the  spinal  column  results ;  but 
occasionally,  when  many  bones  are  affected,  the  vertebrae  and  inter-vertebral 
cartilages  soften,  ami  spinal  curvatures  result.  The  curvatures  are  due  to  the 
weight  of  the  shoulders  and  head  on  the  spinal  column.  They  are,  with 
some  deviations,  an  exaggeration  of  those  present  in  the  normal  state.  Ra- 
chitic curvatures  are,  therefore,  mainly  antero-posterior  with  some  lateral 
deflections.  Where  there  is  much  curvature,  the  vertebrae  become  wedge- 
shaped,  narrowed  upon  the  concavity,  and  thickened  upon  the  convexity. 
The  inter-vertebral  cartilages  are  also  more  or  less  changed  by  the  pressure, 
being  thinned  where  the  vertebrae  approximate  to  each  other,  on  the  concave 
aspect  of  the  curvature,  and  of  normal  thickness  or  thicker  than  normal  upon 

the  convexity.  The  accompanying  wood-cut  exhibits 
the  nature  and  appearance  of  rachitic  spinal  curva- 
ture in  the  adult.  Rachitis,  having  occurred  at  the 
usual  age,  resulted  in  the  permanent  deformity  here 
illustrated.  In  extreme  cases,  fortunately  rare,  the 
functions  of  important  organs  may  be  seriously  im- 
paired by  the  curvature  and  consequent  compression, 
as  in  Pott's  disease.  Thus,  according  to  Miller,  the 
aorta  has  been  so  doubled  upon  itself  as  to  materially 
diminish  the  flow  of  blood  to  the  lower  extremities, 
and  to  thus  sensibly  impair  their  nutrition.  The 
effect  of  so  great  curvature  upon  the  functions  of  the 
heart  and  lungs  must  obviously  be  detrimental. 

At  first  the  spinal  curvatures  disappear  when  the 
child  reclines,  or  is  lifted  by  the  axilla?,  so  as  to  raise 
the  head  and  shoulders  from  the  spine,  but  when  the 
deformity  has  continued  so  long  that  the  vertebrae 
and  cartilages  have  become  wedge-shaped,  it  remains 
for  life,  or  cau  only  be  rectified  slowly  and  with  dif- 
ficulty by  mechanical  appliances.  As  seen  in  the 
wood-cut,  the  common  curvature  in  the  dorsal  region 
is  backward  (kyphosis),  while  to  compensate  the  pa- 
tient instinctively  carries  the  neck  forward,  with  the 
head  thrown  back,  causing  cervical  lordosis,  a  similar 
anterior  curvature  being  common  in  the  lumbar  re- 
gion. Lateral  curvature  (scoliosis)  may  or  may  not 
bo  present,  even  when  there  is  considerable  antero-posterior  flexure.  Scoliosis 
is  sometimes  produced  by  the  nurse,  in  carrying  the  infant  habitually  over 
One  arm. 


Rachitic  spinal  curvature  in  an 
ailult.  (From  a  specimen  in  the 
Wood  Museum,  Bellevne  Hospi- 
tal.) 


Changes  in  the  Maxilhe. — Fleischmann  has  investigated  the  changes  which 
rachitis  produces  in  the  maxillary  bones.  Stunted  growth  of  the  facial 
bones,  generally,  has  long  been  known,  and  has  been  remarked  upon  by  various 
writers  ;  but,  according  to  Fleischmann, other  interesting  changes  occur  in  the 
jaw-bones,  which  affect  the  direction  and  position  of  the  teeth.     According 


ANATOMICAL  CHARACTERS  OF  RACHITIS. 


265 


Fie.  12. 


to  this  author,  the  arched  shape  of  the  lower  jaw  becomes  polygonal,  and  the 
direction  of  the  alveolar  process  also  changes,  so  that  it  inclines  inward. 
This  deviation  in  the  arch,  and  in  the  alveolar  process,  which  begins  in  the 
region  of  the  canine  teeth,  necessarily  causes  shortening  of  the  lower  jaw. 
Commencing  soon  after,  a  change  is  observed  in  the  upper  jaw-bone  from  the 
zygomatic  arch  forward,  so  as  to  cause  lengthening  of  this  bone,  changing 
here  also  the  shape  of  the  arch  and  the  position  of  the  teeth.  The  lateral 
incisors,  instead  of  being  in  front,  have  a  lateral  position,  and  the  incisors 
and  molars  diverge,  so  that  when  the  jaws  are  closed  they  overlap  the  corre- 
sponding teeth  of  the  lower  jaw  in  front  and  upon  the  sides,  a  condition  the 
opposite  of  that  seen  in  the  jaws  of  old  people.  Fleischmann  attributes  these 
changes  in  the  lower  jaw  to  the  action  of  the  masseter  and  mylo-hyoid  mus- 
cles, and  perhaps  the  genio-glossus,  and  to  pressure  of  the  lip,  the  deficiency 
of  earthy  salts  in  the  bone  rendering  it  more  easily  acted  on  by  the  muscles. 
The  change  in  the  upper  jaw-bone  he  attributes  to  lateral  pressure  of  the 
zygomatic  arches. 

Changes  in  the  Ribs. — The  ribs  are  early  affected  in  rachitis.  The  swelling 
of  their  anterior  ends,  where  they  unite  with  the  costal  cartilages,  producing 
the  "  rachitic  rosary,"  has  been  already 
alluded  to  as  one  of  the  first  and  most 
conspicuous  signs  of  rachitis.  The  costo- 
chondral  articulations  are  enlarged  in  all 
directions,  appearing  as  nodules  under 
the  skin.  If  an  opportunity  occur  of 
inspecting,  at  an  autopsy,  the  pleural 
surface,  the  nodular  prominences  are  seen 
to  be  even  greater  and  more  distinct  there 
than  under  the  skin. 

The  deformity  of  the  thorax  conse- 
quent upon  softening  of  the  ribs  is  inter- 
esting. Commencing  with  the  spine,  the 
ribs  extend  nearly  directly  outward  ;  at 
the  union  of  the  dorsal  and  lateral  re- 
gions, they  make  a  short  curve  forward, 
and  then  turn  inward,  also  with  a  short 
curve  toward  the  sternum  (Fig.  13).  This 
abrupt  bending  of  the  ribs,  which,  in 
their  softened  state,  has  been  caused  by 
atmospheric  pressure  during  respiration, 
produces  a  depression  in  the  thoracic 
wall  at  about  the  point  where  the  ribs 
and  their  cartilages  unite.  A  groove  ex- 
tends on  the  antero-lateral  surface  of  the 
thorax  from  the  second  or  third  rib 
downward,  and  a  little  outward.  Sometimes  the  bottom  of  the  groove  is  oc- 
cupied by  the  costo-chondral  joints ;  in  other  cases  these  joints  are  a  little 
to  one  side  of  the  deepest  part  of  the  groove.  The  transverse  diameter, 
therefore,  of  the  anterior  half  of  the  thorax  is  much  less  than  in  health.  This 
necessarily  diminishes  the  lateral  expansion  of  the  lung  in  inspiration,  and 
causes  unusual  prominence  of  the  sternum.  Hence  the  expressions  "pigeon- 
breasted,"  "resemblance  to  the  prow  of  a  ship,"  etc.,  applied  to  this  deformity. 
The  presence  of  the  heart  renders  the  groove  more  shallow  on  the  left  side, 
at  the  fourth  and  fifth  ribs,  than  on  the  opposite  side,  since  this  organ  affords 
partial  support  to  the  chest-wall.     On  the  other  hand,  the  right  groove  is 


Rachitic  child  with  characteristic  deformity  of 
head,  ribs,  and  radius.  (From  a  patient  in  the  Xew 
York  Foundling  Asylum.) 


266 


RACHITIS. 


not  as  long  as  the  left,  as  the  lower  ribs  on  this  side  are  partially  supported 
by  the  liver.  On  both  sides,  however,  the  lower  part  of  the  thorax,  that  below 
the  seventh,  eighth,  or  ninth  ribs,  widens,  being  pressed  outward  and  sup- 
ported by  the  abdominal  viscera.  There  is,  therefore,  in  addition  to  the  longi- 
tudinal groove,  an  antero-posterior  depression,  sometimes  also  spoken  of  as  a 
furrow  or  groove,  on  either  side,  lying  between  the  sixth  and  ninth  ribs. 

The  ribs  with  their  attached  muscles  are  important  agents  in  respiration, 
but  the  soft  and  yielding  nature  of  the  ribs,  in  the  rachitic,  retards,  and  to  a 
great  extent  prevents,  the  lateral  expansion  of  the  thorax  which  is  necessary 
tor  normal  and  full  inspiration.  The  action  of  the  respiratory  muscles, 
and  the  pressure  from  within  of  the  air  descending  along  the  air  passages,  is 

Fig.  13. 


Deformity  of  chest  in  rachitis. 

not  sufficient  to  fully  overcome  the  external  atmospheric  pressure,  in  the  ab- 
sence of  proper  resiliency  of  the  ribs.  Consequently,  with  each  inspiration, 
we  observe  more  or  less  sinking  in  of  the  thorax  on  either  side,  just  as  when 
a  moderate  obstruction  to  the  entrance  of  air  exists  in  the  larynx  or  trachea. 
As  the  ribs  become  firmer  from  the  deposit  of  lime  salts,  resjiiration  is  more 
regular  and  normal. 

Changes  in  Bones  of  Upper  Extremity. — Although  swelling  of  the  lower 
end  of  the  radius  (see  Fig.  12)  is  one  of  the  earliest  signs  of  rachitis,  the 
bones  <>!'  the  upper  extremities  are  less  frequently  curved  and  distorted  than 
those  "of  the  lower  extremities.  The  clavicle  sometimes  softens  and  bends, 
producing  two  curvatures,  one  backward,  near  the  scapula,  and  another  of 
larger  size  nearer  the  sternum,  directed  forward  and  a  little  upward.  Careful 
examination  shows,  in  some  rachitic  patients,  thickening  of  the  margins  of 
the  scapula,  like  that  of  the  cranial  bones.     The  humerus  is  occasionally  bent, 


ANATOMICAL    CHARACTERS    OF    RACHITIS. 


267 


and  usually  at  the  point  of  insertion  of  the  deltoid,  in  consequence  of  the 
powerful  action  of  this  muscle  in  raising  and  supporting  the  arm.  The 
radius  and  ulna  are  bent  outward  and  twisted.  This  deformity  is  attributed 
by  Sir  William  Jenner  to  the  fact  that  ricketty  children  support  themselves, 
while  in  the  sitting  posture,  upon  the  palms  of  the  hands  pressed  upon  the 
floor  or  couch.  Supporting  the  weight  of  the  body  in  this  way,  not  only,  in 
his  opinion,  causes  bending  of  the  ulna  and  radius,  but  also  aids  in  producing 
the  deformities  of  the  humerus  and  clavicle. 

Changes  in  Bones  of  Pelvis. — The  deformities  of  the  pelvic  bones,  resulting 
from  rachitic  softening,  are,  in  the  female  infant,  the  most  important  of  any 
which  the  skeleton  undergoes.  They  are  produced  by  pressure  from  above 
of  the  abdominal  organs,  serving  to  widen  the  brim  of  the  pelvis,  and  also 
by  pressure  of  the  spinal  column,  sustaining  the  weight  of  the  trunk,  shoulders, 
and  head,  pressing  forwards  the  promontory  of  the  sacrum,  in  the  sitting  pos- 
ture, and  thus  diminishing  the  antero-posterior  diameter  of  the  pelvic  brim. 
There  is,  moreover,  twofold  pressure  from  below,  that  caused  by  the  heads  of 
the  thigh  bones,  in  standing,  and  that  exercised  by  the  tuberosities  of  the 
ischia,  in  sitting.  Both  these  forms  of  pressure  have  a  tendency  to  narrow 
the  outlet  of  the  pelvis.  Hence  the  marriage  of  the  female  who  has  been 
rachitic  in  infancy  may  involve  serious  consequences.     Many  of  the  tedious 


Fig.  14. 


Fig.  15. 


Fig.  16. 


Rachitic  deformities  of  the  pelvis.     (From  specimens  iu  the  Wood  Museum.) 

instrumental  labors  in  the  families  of  the  city  poor,  which  severely  tax  the 
patience  and  endurance  of  young  practitioners,  are  attributable  to  rickets  in 
early  life. 

Changes  in  Bones  of  Lower  Extremity. — The  curvature  of  the  femur  is  usu- 
ally forward,  or  forward  and  outward.     The  neck  of  the  femur  sometimes 


Fig.  17. 


Fig.  IS. 


Rachitic  deformities  of  the  femur.     (Wood  Museum.) 


bends  by  the  weight  of  the  body,  or  by  use  of  the  legs,  so  that  the  angle 
which  it  forms  with  the  shaft  is  changed.     The  annexed  wood-cuts  show  the 


268 


RACHITIS. 


rachitic  bend  of  this  bone  in  an  adult,  years  after  rachitis  had  ceased,  and 
when  the  bone  had  become  consolidated  by  the  new  deposition  of  lime  salts. 
The  curvature  of  the  tibia  and  fibula  varies.  In  those  under  the  age  of  one 
year,  it  is  apt  to  be  outward,  so  that  the  knees  are  separated  from  each  other. 
In  those  old  enough  to  stand,  the  weight  of  the  body  usually  determines  a 
forward  bending  of  these  bones.  In  one  case  in  my  practice,  an  anterior  cur- 
vature so  abrupt  that  an  angle  of  about  70°  was  formed,  existed  about  four 
inches  above  each  ankle.  This  patient,  though  old  enough  to  walk,  almost 
constantly  sat  during  the  day  with  the  feet  extended  beyond  the  sofa,  so  that 
the  edge  of  the  latter  corresponded  with  the  concavity  of  the  legs.  It  seemed 
to  me  that  the  weight  of  the  feet  must  have  been  a  factor  in  causing  these 
curvatures,  especially  as  the  case  was  one  of  very  marked  rachitic  softening  of 
different  bones.    Still,  tibial  and  fibular  bending  at  this  point  has  been  noticed 

by  different  observers,  who  have  attributed  it  to  the 
weight  of  the  body  in  walking.  Various  other  cur- 
vatures, besides  those  mentioned,  occur  in  the  bones 
of  the  lower  extremities,  the  direction  in  which  the 
limbs  bend  being  determined  by  the  particular  cir- 
cumstances of  the  case. 


Fig.  19. 


Fie.  20. 


In  mild  cases  of  rickets,  most  of  the  deformities 
described  above  are  lacking,  but  in  typical  cases  cer- 
tain of  them  stand  out  prominently,  so  as  to  be  read- 
ily detected  by  one  familiar  with  the  disease.  In 
all  such  cases  the  diagnosis  is  easy  beyond  that  of 
most  other  maladies,  for  the  changes  which  occur  are 
not  only  conspicuous,  but  pathognomonic. 

Rachitis  produces  another  important  effect  on  the 
skeleton.  Its  growth  is  stunted,  not  only  during  the 
rachitic  period,  but  subsequently,  so  that  those  who 
have  been  rachitic  in  childhood,  unless  very  mildly, 
have  less  than  the  average  stature  in  adult  life.  The 
stunted  growth  is  apparent,  though  ample  allowance 
be  made  for  curvatures.  The  arrest  of  development 
is  greater  in  some  bones  than  in  others.  It  is  greatest 
in  the  bones  of  the  face,  pelvis,  and  lower  extremi- 
ties. Stunted  growth  of  the  pelvic  bones  of  the  fe- 
male infant  conjoined  with  the  deformities  alluded  to 
above,  may  seriously  affect  her  subsequent  life,  and  a 
rachitic  pelvis  in  the  female,  exhibiting  both  stunted 
growth  and  deformity,  constitutes  a  valid  reason  tor 
avoiding  marriage.  As  a  rule,  the  older  the  child 
is  when  rachitis  begins,  the  less  is  the  skeleton  affected,  and  the  less  conse- 
quently is  the  deformity. 

Effect  of  Rachitis  on  Dentition. — As  might  be  expected  from  the  nature  of 
rachitis,  dentition  suffers  severely.  It'  the  disease  show  itself  before  any 
tooth  lias  appeared,  the  first  teeth,  to  wit,  the  lower  central  incisors,  will 
probably  not  appear  before  the  ninth  or  tenth  month,  or  even  later.  Sir 
Wm,  Jenner  considers  the  non-appearance  of  a  tooth  by  the  ninth  month, 
with  few  exceptions,  a-  sign  of  rachitis.  Teeth  which  appear  during  the 
rachitic  state  arc  frail,  deficient  in  enamel,  and  crumble  readily.  They  become 
carious,  rot,  and  break  before  the  usual  time.  If  certain  teeth  have  ap- 
peared when  rachitis  begins,  several  months  elapse  before  others  cut  the  gum. 
It  is  even  said  that  a  child  who  has  rachitis  severely  may  never  have  a  tooth ; 


Rachitic  deformities  of  the  fe- 
mur, tibia,  and  fibula.  (Wood  Mu- 
seum.) 


ANATOMICAL    CHARACTERS    OF    RACHITIS.  269 

may  remain  toothless  for  life:  but  I  have  never  observed  such  a  case.  Ordi- 
narily, when  the  rachitic  state  ceases,  and  the  health  is  fully  restored,  denti- 
tion goes  on  as  before.  The  arrest  of  teething,  so  easily  observed,  has  long 
been  considered  one  of  the  most  reliable  diagnostic  signs.  The  physician 
cannot  justly  pronounce  on  the  nature  of  the  disease  in  a  case  of  suspected 
rachitis,  unless  he  first  carefully  inspects  the  gums. 

Changes  in  the  Soft  Tissues. — Although  the  conspicuous  lesions  of  rickets 
pertain  to  the  skeleton,  the  soft  tissues  are  also  more  or  less  implicated.  The 
ligaments  become  relaxed  and  flabby,  giving  unusual  mobility  to  the  joints, 
and  unsteadiness  to  the  movements.  The  fibrous  bands  which  unite  the  ver- 
tebra?, as  well  as  the  ligaments  of  the  extremities,  participate  in  the  relaxa- 
tion. In  certain  patients,  the  muscles  throughout  the  system,  partly,  perhaps, 
in  consequence  of  the  gastro-intestinal  disturbance,  indigestion,  and  mal-nutri- 
tion ;  partly,  perhaps,  from  want  of  use  (for  the  rachitic  are  apt  to  be  quiet), 
become  shrunken  and  flabby.  The  spleen  is  frequently  enlarged,  as  ascertained 
by  palpation  and  percussion.  Ritter  Von  Rittershain  found  this  organ  deci- 
dedly enlarged  in  ten  out  of  thirty-five  cases  which  he  examined  after  death. 
The  enlargement  is  the  result  of  cellular  proliferation,  common  in  diseases 
which  are  attended  by  dyserasia.  The  liver  in  many  patients  undergoes  no 
perceptible  change,  except  that  it  may  be  pushed  a  little  downwards."  It  is 
occasionally  found  enlarged  from  fatty  infiltration,  but  no  special  significance 
attaches  to  this,  for  fatty  liver  is  common  in  various  forms  of  disease  attended 
by  innutrition  and  wasting.  It  is  common  in  tuberculosis,  and  in  protracted 
intestinal  catarrh,  and  its  pathological  significance  appears  to  be  the  same  in 
these  various  diseases.  There  can  be  little  doubt  that  Sir  Wm.  Jenner  errs 
when  he  states  that  albuminoid  infiltration  of  the  liver  is  common  in  rachitis. 
Parry,  Gee,  Dickinson,  and  Senator  agree  that  it  is  rare,  and  that  if  it  does 
occur,  it  is  by  coincidence. 

In  a  discussion  on  rachitis,  in  the  London  Pathological  Society,  Dr.  Dickinson1  spoke 
of  enlargement  of  the  spleen,  liver,  and  lymphatic  glands,  which  he  had  observed  in 
rachitic  cases.  According  to  him,  the  spleen  undergoes  the  greatest  enlargement,  the 
lymphatic  glands  the  least,  and,  of  the  latter,  "  the  mesenteric  glands  show  the  most  de- 
cided swelling."  Exceptionally,  the  spleen  is  so  large  that  it  occupies  the  greater  part 
of  the  left  half  of  the  abdominal  cavity,  but  a  less  degree  of  enlargement  is  the  rule. 
The  liver  is  apt  to  extend  one  or  two  inches  below  the  ribs.  The  swelling,  Dr.  Dick- 
inson adds,  is  not  amyloid.  "  There  is  no  new  growth  or  deposit,  only  an  irregular 
development  of  the  proper  tissues  of  the  organs."  Both  the  corpuscular*  and  intersti- 
tial elements  are  increased  in  the  liver,  spleen,  and  lymphatic  glands.  But  other 
members  of  the  society  had  observed  this  enlargement  only  in  occasional  cases,  and 
they  considered  it  due  rather  to  the  state  of  health  which  caused  rachitis  than  to  rachitis 
itself.  Dr.  C.  Hilton  Fagge  stated  that  he  had  failed  to  find  swelling  of  the  liver,  spleen, 
or  lymphatic  glands,  in  a  large  majority  of  cases.2  An  undue  development  of  the  lym- 
phatic glands  from  hyperplasia  is  very  common  in  children  in  various  states  of  ill-health. 
and  the  mesenteric  glands  are  especially  apt  to  become  enlarged  from  this  cause  in  pro- 
tracted cases  of  intestinal  catarrh  or  irritation. 

The  abdomen  is  protuberant  from  various  causes.  The  lateral  depression  of 
the  thoracic  walls  causes  the  liver  and  spleen  to  descend  a  little  lower  in  the 
abdominal  cayfty  than  natural.  The  enlargement  of  the  liver  and  spleen, 
the  feeble  tonicity  of  the  intestinal  muscular  fibres,  and  consequent  distension 
of  the  intestines  with  gas,  and  the  rachitic  shortening  of  the  spinal  column, 
which  causes  approximation  of  the  ribs  and  pelvis,  tiecessarilv  produce  ab- 
dominal protuberance. 

'  Lancet,  December  11,  1S80.  2  Lancet,  November  20,  1880. 


270  RACHITIS. 

The  kidneys  themselves  are  not  diseased  in  rickets,  but  there  is  an  exagge- 
rated discharge  of  phosphates  in  the  urine,  and,  as  stated  above,  lactic  acid 
and  free  phosphoric  acid  have  been  found  in  this  excretion.  The  urine  is 
commonly  pale  ;  its  urea  and  uric  acid  are  diminished  ;  and  it  sometimes  con- 
tains a  sediment  of  oxalate  of  lime. 

The  brain  is  usually  well  developed,  and  appears  healthy,  with  the  normal 
proportion  of  white  and  gray  substance.  In  one  case  the  weight  of  this  organ 
Mas  ascertained  by  Dr.  (?ee  to  be  fifty-nine  ounces,  and  in  another  forty-two 
and  a  half  ounces.  In  both  brains  the  proportions  of  white  and  gray  sub- 
stance, and  their  color  and  consistence,  seemed  normal. 

Anatomical  Characters  of  the  Third  Stage,  or  that  of  Reconstruction. 
— This  stage  will  be  better  understood,  if  we  recollect  what  has  occurred  during 
the  first  and  second  stages.  The  very  vascular  periosteum  is  drawn  tightly 
over  convexities,  the  pressure  upon  which  diminishes  the  hyperemia  and  the 
amount  of  exudation  underneath.  Over  the  concavities  the  periosteum  is 
loose  ;  it  is  hypertemic,  with  abundant  new  capillaries,  the  interspace  between 
it  and  the  bone  being  tilled  with  the  gelatiniform  substance  already  described. 
The  reparative  process  goes  forward  more  rapidly,  and  the  deposition  of  lime 
salts  is  more  abundant  upon  the  concave  surfaces,  where  there  have  been  free 
exudation  and  no  compression  of  the  capillaries,  than  elsewhere.  The  lime 
salts  are  deposited  from  the  blood.  Consequently,  from  the  increased  capillary 
circulation  and  hyperamiic  state  of  the  periosteum  produced  by  rachitis,  the 
chalky  matter  is  rapidly  effused  wherever  there  is  an  open  space  under  the 
periosteum,  and  where  the  capillaries  are  in  a  state  of  engorgement.  Hence 
the  reconstructed  bone  is  thicker  and  firmer  upon  the  concave  aspect  of  the 
long  bones  than  elsewhere,  and  thinnest  upon  the  convex  aspect  where  the 
periosteum  is  more  tense,  and  its  capillaries  more  or  less  compressed. 

It  is  a  question  whether  true  ossitication  occurs  at  first  during  the  repara- 
tive stage.  The  deposition  of  chalky  matter  is  designated  by  some  writers 
as  a  petrifaction  rather  than  a  true  bone-formation.  Trousseau  likens  it  to 
the  formation  of  callus  after  a  fracture.  It  certainly  produces  a  substance 
more  compact  than  ordinary  bone.  The  term  "eburnation"  has  been  applied 
to  this  new  osseous  formation,  and  I  have  designated  it  "osteo-sclerosis." 
Some  years  since  I  examined  microscopically  an  adult  bone  which  exhibited 
the  rachitic  curvature  in  a  marked  degree,  and  was  very  hard.  It  contained 
the  elements  of  true  bone,  but  I  was  in  doubt  whether  the  part  examined 
was  formed  during  convalescence  from  rickets,  or  in  the  subsequent  growth. 

Recovery  from  rickets  is  gradual.  Little  by  little,  the  cartilaginous  and 
periosteal  proliferation  ceases,  the  hyperemia  abates,  and  the  bone-producing 
tissues  return  to  their  normal  state.  Certain  of  the  deformities  are  perma- 
nent, but  others  disappear  in  the  further  growth  of  the  skeleton. 


Symptoms  of  Rachitis. 

Preceding  and  accompanying  rachitis,  symptoms  may  be  present  which  are 
due  to  indigestion  and  intestinal  catarrh,  such  as  flatulence,  unhealthy  stools, 
and  poor  or  capricious  appetite.  When  rachitis  begins,  the  infant  becomes 
fretful;  its  sleep  is  apt  to  be  restless  and  disturbed,  and  it  awakens  often.  It 
repels  attempts  to  amuse  it,  and  is  apparently  annoyed  by  them.  Nurse  and 
mother  speak  of  it  as  a  cross  child.  It  perspires  freely  from  the  head  and 
neck, both  when  awake  and  when  asleep,  while  the  extremities  and  trunk  arc 
dry.  its  pillow  is  wet  with  perspiration  during  sleep,  and  sweat  drops  may 
be  seen  upon  forehead  and  face.     If  the  surface  be  dry,  a  little  excitement  or 


COMPLICATIONS    AND    SEQUELS    OF    RACHITIS.  271 

elevation  of  temperature  causes  the  perspiration  to  appear.  The  rachitic 
child  does  not  well  tolerate  the  bedclothes,  and  attempts  to  throw  them  off 
from  its  limbs,  even  in  cool  weather,  lying  exposed,  and  causing  considerable 
annoyance  to  the  nurse  who  strives  to  prevent  its  taking  cold.  Sometimes 
miliaria,  due  to  the  moist  state  of  the  skin,  appear  upon  the  face  and  neck. 
The  subcutaneous  veins  which  return  blood  from  the  head  are  large,  and  the 
jugular  veins  full. 

Another  symptom  is  soon  observed,  to  wit,  tenderness  over  a  considerable 
part  of  the  surface,  perhaps  largely  due  to  the  morbid  state  of  the  periosteum 
over  so  many  bones,  though  it  is  also  experienced  when  pressure  is  made  upon 
soft  parts,  as  the  abdomen.  The  tenderness  is  probably,  in  part,  the  cause  of 
the  fretful  disposition.  The  little  patient  appears  to  dread  to  be  touched ;  its 
flesh  is  sore ;  it  repels  attempts  to  amuse  it,  and  wishes  to  be  quiet.  Dand- 
ling it  upon  the  arms,  swinging  it,  or  even  walking  with  it,  which  delights 
the  healthy  child,  and  elicits  a  smile  or  notes  of  glee,  only  adds  to  its  discom- 
fort. It  is  most  at  ease  when  left  alone,  upon  a  soft  cot  or  pillow,  or,  if  it  have 
craniotabes,  when  quietly  held  over  the  shoulder.  Languor,  disinclination  to 
•use  the  limbs,  or  to  play,  moderate  thirst,  with  other  symptoms  referable  to 
the  digestive  apparatus,  which  are  present  in  many  cases,  and  which  have  al- 
ready been  described,  are  soon  followed  by  changes  in  the  skeleton,  which  are 
perceptible  to  the  sight  and  on  palpation.  The  pulse  and  temperature  in  a 
large  proportion  of  the  ordinary  chronic  cases,  do  not  deviate  from  the  healthy 
state,  except  that  in  some  patients  there  is  a  slight  febrile  movement  in  the 
latter  part  of  the  day. 

Although  rachitis  is  ordinarily  a  chronic  disease,  insidious  in  its  commence- 
ment, gradual  and  progressive  in  its  development,  occupying  months,  there  is 
an  acute  form  which  is  attended  by  more  marked  febrile  movement  and  ten- 
derness, and  in  which  the  articular  swelling  appears  more  quickly. 

A  bruit  de  soufflrt,  of  greater  or  less  intensity,  synchronous  with  the  pulse, 
has  frequently  been  heard  in  rachitic  cases  by  applying  the  ear  over  the  ante- 
rior fontanelle.  Drs.  Whitney  and  Fischer,  New  England  physicians,  first 
called  attention  to  this  murmur,  believing  it  to  be  a  sign  of  chronic  hydro- 
cephalus. MM.  Billiet  and  Barthez  heard  it  in  cases  of  rachitis,  and,  there- 
fore, concluded  that  the  American  physicians  had  confounded  the  two  diseases. 
More  recent  observations  have  established  the  fact  that  this  bruit  has  little 
diagnostic  value.  It  is  heard  whenever  there  is  sufficient  patency  of  the  an- 
terior fontanelle,  both  in  health  and  disease,  for  sound  is  conducted  better 
through  a  membrane  than  through  bone.  Dr.  Wirthgen  heard  the  bruit  in 
22  out  of  52  children,  of  whom  all  except  four  were  in  "good  health.  I  have 
auscultated  the  anterior  fontanelle  in  29  infants,  who  were  with  two  excep- 
tions between  the  ages  of  three  and  thirty  months.  All  were  well,  or  affected 
merely  with  trivial  ailments  which  did  not  affect  the  cerebral  circulation. 
In  most  of  them  a  murmur  could  be  distinctly  heard,  synchronous  with  the 
respiratory  act,  and  in  15  of  the  29  cases  no  other  sound  could  be  detected, 
while  in  the  remaining  14  a  bruit  could  be  detected,  synchronous  with  the 
pulse. 

Complications  and  Sequelae  of  Rachitis. 

These  have  been  in  part  described  in  the  foregoing  pages,  but  there  are  cer- 
tain other  results  of  the  disease  to  which  it  is  proper  to  call  attention.  If 
the  deformity  in  the  thoracic  wall,  namely,  the  lateral  depression  of  the  ribs 
and  anterior  projection  of  the  sternum,  be  great,  we  would  naturally  expect 
that  the  two  important  organs  underneath,  the  heart  and  lungs,  would  receive 
some  detriment.     Upon  the  surface  of  the  heart,  at  the  point  where  it  sup- 


272  RACHITIS. 

ports  the  softened  ribs,  a  white  patch  is  often  found,  due  to  thickening  of  the 
pericardium  and  proliferation  of  the  endothelial  cells,  just  as  thickening  of  the 
skin  in  the  palm  of  the  hand  occurs  from  friction  and  pressure  upon  that  part. 
It  is  probable  that  this  pressure  does  not  seriously  impair  the  function  of  the 
heart,  but  it  may  increase  the  weakness  of  its  movements  in  any  asthenic 
disease  which  may  occur  during  the  rachitic  period.  The  injury  sustained 
by  the  lungs  is  greater  and  more  apparent.  If  the  ribs  be  flexible,  and  much 
depressed,  full  inflation  of  the  lung  cannot  occur  in  those  parts  where  the 
depression  is  greatest.  Semi-collapse  of  certain  lobules  is  apt  to  occur,  and 
even  complete  collapse  of  the  distant  thin  edges  of  the  lung.  The  stress  of 
respiration  falls  unequally  upon  different  parts  of  the  lung.  The  anterior 
portion,  which  ascends  with  the  sternum  as  that  is  propelled  forward,  is 
more  fully  dilated  than  the  lateral  and  posterior  parts,  and  hence  is  apt  to 
become  emphysematous.  If  in  this  state  of  the  thorax  and  lungs,  severe 
bronchitis  or  broncho-pneumonia  arise,  the  state  is  one  of  great  peril.  The 
mucus  and  pus  being  expectorated  with  difficulty,  clog  the  tubes  and  produce 
dyspnoea.  Full  inspiration  in  the  lateral  and  depending  portions  of  the  lung, 
which  is  required  in  order  to  expel  the  mucus,  not  occurring,  the  result  may 
be  unfavorable,  even  in  comparatively  mild  forms  of  inflammation.  Bron- 
chitis and  broncho-pneumonia  are  the  causes  of  death  in  not  a  few  cases  of 
severe  rickets.  Certain  writers  state  that  chronic  hydrocephalus,  diarrhoea, 
and  eclampsia  may  complicate  rachitis.  I  have  not  seen  any  case  in  which 
rickets  seemed  to  sustain  a  causative  relation  to  either  hydrocephalus  or  diar- 
rhoea, but  we  know  that  diarrhoea  frequently  precedes  and  accompanies 
rachitis,  and  its  relation  to  it  is  that  of  cause  rather  than  effect.  This  sub- 
ject has  been  sufficiently  treated  of  in  preceding  pages.  Rachitic  infants  ap- 
pear to  be  more  liable  to  eclampsia  than  those  who  are  healthy.  This  would 
be  inferred  from  their  liability  to  laryngismus  stridulus,  for  there  is  a  simili- 
tude in  the  nature  of  these  neuroses. 


Diagnosis  of  Rachitis. 

Rachitis  in  many  instances  continues  a  considerable  time  before  its  nature 
is  suspected,  the  symptoms  to  which  it  gives  rise  being  overlooked,  or  attrib- 
uted to  other  causes  than  the  true  one ;  and  yet  it  is  important  that  an  early 
diagnosis  be  made,  for  it  is  much  more  amenable  to  treatment  in  its  early  than 
in  its  later  stages.  The  deformities  which  mar  the  beauty,  and  to  a  certain 
extent  impair  the  activity  and  usefulness,  of  so  many  who  have  been  rachitic 
in  childhood,  may  often  be  prevented  by  early  diagnosis  and  treatment. 
Many  with  this  disease  do  not  show  the  usual  signs  of  faulty  digestion  and 
innutrition,  especially  on  casual  inspection,  for  there  may  be  considerable 
adipose  development  and  rotundity  of  features  and  form  in  a  rachitic  child  ; 
while,  on  the  other  hand,  there  are  numerous  instances  of  mal-nutrition  and 
wasting  without  rachitis.  Early  diagnosis,  when  the  affection  is  of  a  mild 
type,  is  necessarily  difficult,  but  a  watchful  and  painstaking  physician  will 
commonly  detect  the  disease  before  it  has  run  many  weeks,  if  he  bears  in  mind 
its  frequency,  and  looks  carefully  for  it. 

If  called  to  a  suspected  case,  we  should  inquire  into  the  history,  and  par- 
ticularly whether  there  have  been  signs  of  intestinal  catarrh  or  innutrition* 
The  gums  should  be  inspected  to  ascertain  whether  there  is  backwardness  in 
dentition, and  the  head,  to  note  its  shape  and  size,  whether  it  is  elongated,  or 
whether  it  approximates  the  square  shape,  with  broad  forehead  and  large 
protuberances.  We  ahould  notice  also  the  state  of  the  fontanelles  and  sutures, 
and  whether  there  are  softening  and  thinning  of  the  cranial  bones.      The 


PROGNOSIS   OF   RACHITIS.  273 

costo-chondral  articulations  and  those  of  the  wrist,  should  also  be  carefully 
examined  to  ascertain  if  there  is  any  enlargement,  and  the  shape  of  the  tho- 
rax, which  begins  to  exhibit  the  rachitic  deformity  at  an  early  stage  of  the 
disease,  should  likewise  be  noticed.  We  should  also  examine  the  child  in 
reference  to  other  less  prominent  signs,  such  as  spinal  curvature,  abdominal 
protuberance,  muscular  weakness,  and  relaxation  of  ligaments  (which  produce 
feeble  and  unsteady  use  of  the  limbs),  perspirations  upon  the  head  and  neck 
from  slight  excitement,  and  during  sleep,  fretfulness,  etc.  If  rachitis  be  pre- 
sent, certain  of  these  signs  will  be  observed. 

The  late  Dr.  Parry  called  attention  to  the  importance  of  making  a  differ- 
ential diagnosis  between  the  pseudo-paraplegia  of  rachitis  and  true  paraplegia, 
which  is  the  prominent  symptom  of  infantile  paralysis.  The  rachitic  child, 
from  muscular  weakness  and  ligamentous  relaxation,  and  from  the  soreness 
and  tenderness  common  in  this  condition,  may  seldom  use  his  legs ;  may  sit 
or  lie  quietly  at  the  age  when  healthy  children,  if  awake,  are  constantly 
moving  their  limbs.  If  we  attempt  to  make  him  walk  or  stand,  his  legs  may 
be  so  limp  and  powerless  that  they  give  way  under  his  weight,  but  this  is  a 
different  state  from  paralysis.  In  paralysis,  the  fault  is  in  the  nervous  sys- 
tem— usually  in  the  nervous  centres — whereas,  in  rachitis,  it  is  in  the  mus- 
cles and  ligaments.  The  rachitic  child,  when  sitting  or  lying  down,  readily 
moves  his  legs  if  his  feet  be  tickled  or  pinched,  while  the  paralyzed  limb 
responds  to  the  irritation  imperfectly.  In  infantile  paralysis,  the  loss  of  mus- 
cular power  is,  with  few  exceptions,  confined  to  the  muscles  of  the  lower  ex- 
tremities ;  but  in  rachitis,  the  muscular  feebleness  is  more  general,  being 
noticeable  in  the  arms  as  well  as  in  the  legs.  Great  relaxation  of  the  liga- 
ments is  in  most  instances  due  to  rachitis.  It  is  especially  noticeable  in  the 
ankle  and  knee-joints,  and  is  a  diagnostic  sign  which  should  not  be  overlooked 
in  the  examination  of  a  suspected  case  of  the  disease.  ■ 


Prognosis  of  Rachitis. 

The  prognosis  of  rickets  is  usually  favorable,  provided  that  no  serious  com- 
plication, arises.  Rachitis  is  not  in  itself  fatal,  under  ordinary  circumstances. 
If  there  be  much  lateral  depression  and  narrowing  of  the  thorax,  the  func- 
tions of  the  heart  and  lungs  may  be  embarrassed,  and  if  the  patient  have  a 
severe  bronchial  catarrh,  or  broncho-pneumonia,  the  condition  becomes  one  of 
danger.  Rachitic  children  seem  to  be  especially  liable  to  catarrhal  attacks  of 
the  air  passages,  and  even  a  moderate  catarrh,  with  a  deformed  thorax,  may 
prevent  proper  decarbonization  of  the  blood,  and  cause  livid  ity  and  dyspnoea. 
Therefore,  now  and  then,  a  rachitic  child  succumbs  to  an  attack  of  inflam- 
mation of  the  respiratory  apparatus,  which  would  not  have  been  fatal  if  there 
had  been  no  rachitic  deformity.  We  have  seen  that  in  whatever  way  it  may 
act  to  produce  this  form  of  spasm,  rachitis  is  a  cause  of  laryngismus  stridulus. 
Occasionally  spasm  of  the  glottis  is  fatal,  but  cases  with  such  a  termination 
are  rare  in  America,  though  not  infrequent  in  some  European  countries. 

Of  the  diseases  of  childhood  which  rachitic  children  tolerate  badly,  and 
which  may  prove  fatal  in  consequence  of  rachitic  bone-softening  and  de- 
formity, pertussis  should  be  mentioned.  If  this  be  severe  while  the  ribs  are 
soft  and  yielding,  and  there  be  lateral  depression  of  the  thorax,  the  spasmodic 
cough  produces  great  suffering  and  involves  danger.  Lividity,  feeble  action 
of  the  heart,  pulmonary  and  cerebral  congestion,  and  eclampsia,  may  occur. 
Measles,  if  it  be  attended  by  considerable  bronchitis,  and  especially  if  it  be 
complicated  by  broncho-pneumonia,  is  also  one  of  the  dangerous  intercurrent 
diseases.  The  gravity  of  these  inflammations  of  the  respiratory  apparatus  is 
vol.  i. — 18 


274  RACHITIS. 

usually  proportionate  to  the  degree  of  recession  of  the  ribs  during  inspiration. 
With  these  exceptions,  and  with  that  of  risk  to  the  married  female  who  has 
deformity  and  stunted  growth  of  the  pelvic  bones,  the  rachitic  are  not  liable 
to  any  ulterior  serious  consequences.  Minor  deformities,  in  mild  cases,  not 
infrequently  disappear  in  the  subsequent  growth  of  the  skeleton.  The  older 
the  child  is  when  rachitis  begins,  the  milder  is  ordinarily  the  form  of  the 
disease,  and  the  more  speedy,  consequently,  the  recovery,  and  the. less  the 
deformity.  In  the  gravest  cases,  the  disease  will  almost  always  be  found  to 
have  begun  under  the  age  of  one  year. 


Treatment  of  Rachitis. 

The  correct  treatment  of  rachitis  is  evident  when  we  consider  its  character 
and  the  nature  of  its  causes.  The  obvious  indication  is  to  restore  healthy 
nutrition.  This  requires  both  hygienic  and  therapeutic  measures.  The 
apartment  in  which  the  child  resides  should  be  dry,  airy,  and  plentifully 
supplied  with  light.  He  should  be  taken  daily  into  the  open  air,  in  order  to 
invigorate  his  system,  but  in  such  a  way  as  not  to  increase  his  suffering,  on. 
account  of  his  general  tenderness.  Residence  in  the  country  is  far  preferable 
to  that  in  the  city,  because  of  the  better  hygienic  conditions  which  it  pro- 
cures. The  purer  air,  the  better  diet,  and  consequently  the  more  robust  de- 
velopment gained  by  rural  life,  are  important  advantages,  to  obtain  which  is 
abundantly  worth  pecuniary  sacrifice  when  the  children  of  a  family  are 
rachitic. 

The  diet  in  rachitis  should  receive  particular  attention,  since  indigestion 
and  gastro-intestinal  derangement  sustain  a  causative  relation  to  so  many 
cases.  Good  breast  milk  ought  if  possible  to  be  obtained  until  the  child  has 
reached  the  age  of  ten  months,  and,  if  the  mother's  condition  be  such  that  she 
cannot  furnish  it,  a  wet-nurse  should,  if  practicable,  be  employed.  But  after 
the  age  of  six  months  additional  nutriment  is  required.  As  a  rule,  the  infant 
should  be  weaned  at  the  age  of  twelve  months,  but  longer  nursing  may  be  best 
under  certain  conditions,  as  the  presence  of  hot  weather,  an  abundant  supply 
of  good  breast  milk,  and,  on  the  part  of  the  infant,  feeble  digestion  and  easily 
deranged  digestive  organs.  In  case  breast-milk  cannot  be  obtained,  cow's 
milk,  properly  diluted,  according  to  the  age,  with  water,  or  with  a  solution 
of  one  of  the  foods  for  infants  which  the  shops  contain,  is  probably  the  best 
substitute.  I  have  stated  that  rachitis  seldom  appears  before  the  age  of  three 
or  four  months.  For  an  infant  of  four  months,  cow's  milk  should  be  diluted 
with  about  one-fourth  part  of  water,  but  after  the  age  of  six  months  no  dilu- 
tion is  required.  I  prefer  to  sweeten  the  milk  not  with  cane  sugar,  but  with 
Liebig's  infant's  food,  prepared  by  Hawley,  Horlick,  or  Mellen.  Condensed 
milk  is  now  much  used  in  the  cities,  and  is  prepared  by  American  companies 
as  well  as  by  the  Anglo-Swiss  company,  but  it  possesses  no  advantages  over 
ordinary  milk,  if  the  latter  can  be  obtained  fresh  and  sufficiently  often.  It 
possesses  only  the  advantage  that  it  can  be  longer  preserved  without  fermen- 
tative change.  Infants  over  the  age  of  five  or  six  months  require  the  admix- 
ture of  farinaceous  food  with  the  milk,  at  first  in  small  quantity,  but  in 
greater  proportion  as  the  age  increases.  Barley  flour,  oatmeal,  stale  bread 
crumbled  fine,  Ridge's  food,  imperial  granum,  etc.,  of  the  shops,  form  suita- 
ble additions  to  the  milk  diet.  For  infants  of  the  age  of  nearly  one  year, 
considerable  variety  may  be.  allowed  in  the  diet:  a  potato,  baked  and  mashed 
like  lour,  the  juice  of  beef,  stale  bread  and  butter,  soda  cracker  and  butter, 
etc.,  may  be  allowed.  I  have  elsewhere  stated  that  in  one  of  the  institutions 
of  New  York,  rachitis  from  being  common  was  made  to  disappear  almost 


TREATMENT    OF    RACHITIS.  275 

entirely,  by  allowing  a  more  generous  diet,  a  part  of  which  was  the  daily  use 
of  a  little  beef-tea.  Xo  absolute  directions  can  be  given,  however,  as  regards 
the  diet.  Variation  must  be  allowed  according  to  the  season  of  the  year,  and 
individual  peculiarities.  Cow's  milk  disagrees  with  some  infants,  and  in  hot 
weather  with  many;  so  that  it  is  necessary  to  substitute  for  it  some  farinaceous 
food,  with  perhaps  juice  of  meat,  or  the  white  of  egg. 

Medicines  which  improve  the  nutrition  and  general  health  are  all  more  or 
less  useful  in  the  treatment  of  rachitis,  but,  from  the  nature  of  the  disease, 
lime  is  specially  indicated.  I  have  not,  like  some  observers,  discarded  the 
use  of  cod-liver  oil,  believing  that  it  answers  a  good  purpose  in  improving  the 
general  nutritive  process.  The  following  prescription  will  be  found  useful  in 
most  cases:  8.  Olei  morrhuse,  fliv-viij ;  Aqwe  calcis,  Syrupi  calcis  lacto- 
phosphatis,  aa  fsiv. — M.  Of  this,  one  teaspoonful  may  be  given  four  or  five 
times  daily  to  an  infant  of  one  year.  It  may  be  too  laxative  in  the  summer 
months,  when  lime-water  in  milk,  which  is  constipating,  should  be  used 
instead.  Fleischmann  recommends  the  fluorine  compounds  in  order  to 
increase  and  harden  the  enamel  of  the  teeth.  I  have  had  no  experience 
with  these  remedies,  but  the  theory  of  their  use  appears  to  be  sound.  He 
recommends  the  employment  of  fluorine  between  the  tenth  and  eighteenth 
months,  in  the  form  of  the  tooth  pastilles  of  Ehrhardt  or  Hunter,  which  con- 
tain the  neutral  fluoride  of  potassium.     One  of  them  is  administered  daily. 

Among  other  agents  which  may  be  found  useful  may  be  mentioned  the 
compound  syrup  of  the  phosphates,  the  citrate  of  iron  and  quinia,  wine  of 
iron,  the  various  preparations  of  cinchona,  calomba,  etc.,  since  such  tonics 
when  judiciously  administered  aid  in  the  restoration  of  healthy  nutrition. 
When  complications  arise,  the  treatment  should  be  modified  to  meet  the 
exigencies  of  the  case.  Most  of  the  diseases  which  complicate  rachitis  require 
similar  treatment  to  that  which  is  appropriate  in  their  independent  form,  but 
all  measures  of  a  depressing  nature  must  be  uniformly  avoided. 


SCURVY. 


BY 

PHILIP  S.  WALES  M.D. 

SURGEON-GENERAL    OK    THE    UNITED  STATES    NAVY. 


Synonyms. 


Latin,  Scorbutus ;  French,  Scorbut;  Spanish,  Escorbuto ;  Italian,  Scorbuto;  German, 
Scharbock. 

These  appellations  are  derived  from  the  old  Saxon  word  Scnrbock  (ulcer  of 
the  mouth),  or  from  the  Sclavonic  word  Searb  (disease).  We  may  define 
scurvy  as  an  acquired,  constitutional  disease,  determined  by  the  use  of 
improper  diet,  and  almost  wholly  by  abstention  from  succulent  vegetable 
food.  It  is  characterized  by  certain  alterations  in  the  vital,  physical,  and 
chemical  properties  of  the, blood,  and  by  disturbances  of  the  textural  integrity 
of  nearly  all  the  constituent  tissues  and  organs  of  the  body.  The  perverted 
nutrition  is  manifested  by  lassitude,  weariness,  debility,  breathlessness,  loss  of 
muscular  power,  depression  of  spirits,  and  hemorrhagic  extravasations,  par- 
ticularly into  the  skin  of  the  lower  extremities;  the  cutaneous  blotches  (pete- 
chice,  vibices,  ecchymoses)  are  of  varying  size,  color,  and  form.  The  skin 
occasionally  is  the  seat  of  bleeding,  inveterate,  and  sloughing  ulcerations. 
Ecchymotic  discoloration  occurs  also  in  the  mucous  membranes;  the  gums 
become  spongy,  and  bleed  easily,  and  the  sanious  discharges  from  them  infect 
the  breath  with  a  foul  odor.  Blood  is  sometimes  poured  out  into  the  visceral 
cavities  and  canals,  giving  rise  to  the  various  forms  of  local  hemorrhage. 
The  serous  membranes  display  alterations  of  varying  aspect,  caused  by  effu- 
sive or  inflammatory  action.  It  may  happen  that  exudative  products  occur 
in  the  substance  of  the  viscera  and  organs,  in  which  case  they  are  exceedingly 
apt  to  light  up  inflammatory  disturbances. 


History  of  Scurvy. 

There  is  no  reliable  evidence  to  be  found  in  ancient  medical  literature  that 
this  disease  was  known  as  an  independent  and  distinct  pathological  entity. 
Certain  scorbutic  phenomena  were  recognized,  but  always  as  allied  and  linked 
with  those  of  other  and  diverse  morbid  conditions,  as  ergotism,  typhus, 
diphtheritic  stomatitis,  malarial  cachexia,  splenic  disorders,  and  icterus. 
There  can  be  no  doubt,  however,  that  the  conditions  for  its  development  were 
in  early  times  frequently  supplied  by  the  prevailing  and  wide-spread  igno- 
rance and  neglect  of  the  plainest  facts  of  sanitary  prevision,  by  the  frequent 
famines  from  failure  of  crops  or  other  national  calamities,  by  the  movements 

(277) 


278  scurvy. 

of  large  armies  through  uncultivated  territories  or  desert  wastes  where 
food-supplies  were  impossible;  by  the  recurring  sieges  of  large  cities;  and, 
lastly,  by  the  total  neglect  of  horticulture  which  existed  until  a  comparatively 
late  period.  These  are  the  circumstances,  at  least,  which  in  modern  times 
have  made  a  record  teeming  with  the  most  destructive  outbreaks  of  the  dis- 
ease. These  a  priori  considerations  tend  strongly  to  an  affirmative  conclusion 
as  to  the  prevalence  of  scurvy  at  all  periods  of  the  world's  history,  and  render 
it  probable  that  the  failure  to  identify  it  was  simply  due  to  a  lack  of  patho- 
logical discrimination.  Various  allusions  to  diseases  presenting  scorbutic 
phenomena  can  be  gleaned  from  early  authors.  Hippocrates,1  speaking  of 
enlargement  of  the  spleen  (anx^  /**'yas),  enumerates  such  symptoms  as  a  pallid 
skin,  offensive  breath,  disease  of  the  gums,  and  ulcers  of  the  legs ;  and  again 
in  his  description  of  the  i&ibs  a^artr^,  or  convolvulus  sanguineus?  he  covers 
still  more  of  the  scorbutic  symptoms,  mentioning,  in  addition  to  the  fore- 
going, epistaxis  and  impaired  locomotion.  Celsus,3  Aretasus,4  Caelius  Aure- 
lianus,5  Paulus  vEgineta,6  Avicenna,7  and  others,  have  done  little  else  than 
paraphrase  the  clinical  descriptions  of  Hippocrates.  Pliny,8  in  referring  to 
the  army  of  Cresar  Germanicus,  states  that  a  peculiar  disease  of  the  mouth, 
called  stomacace,  or  sceloturbe,  affected  the  soldiers  while  encamped  in  Ger- 
many, near  the  sea-coast,  and  was  attended  with  dropping  out  of  the  teeth 
and  impeded  locomotion ;  and  he  adds  that  in  treating  this  malady  the  Herba 
Britannica  and  fresh  vegetables  were  used  with  success.  And  Strabo9  tells  a 
similar  story  of  a  dangerous  disease  named  aro^axdxr;,  assailing  the  army  of 
.zEtius  Gallus  in  Arabia.  Marcellus10  alludes  to  an  ulcerative  affection  of  the 
mouth,  oscedo,  for  which  he  too  recommends  the  Herba  Britannica,  a  plant 
now  believed  to  be  identical  with  the  Bumex  aquaticus. 

So  run  the  historical  and  medical  records  as  far  as  antiquity  has  shed  any 
light  upon  this  disease,  and  they  are  altogether  too  deficient  and  obscure  to 
authorize  any  conclusion  as  to  the  real  nature  of  the  pathological  processes 
intended  to  be  described.  The  phenomena  of  scurvy  are  so  peculiar,  and  the 
conditions  of  its  occurrence  so  special,  that  it  may  well  excite  surprise  that  it 
was  not  recognized  in  the  earliest  times  by  those  writers  who,  even  now, 
are  accorded  the  highest  credit  for  their  clinical  acumen  and  precision.  An 
explanation  might  be  sought  in  the  fact  that  the  disease  did  not  really  pre- 
vail to  any  great  extent  in  the  mild  climate  and  fertile  lands  of  the  south  of 
Europe,  in  which  the  literary  and  medical  writers  of  antiquity  chiefly 
flourished,  .and  where,  it  is  well  known,  succulent  vegetables  grew  luxuri- 
antly, and  formed  a  part  of  the  common  diet  of  all  classes  of  people. 

It  is  stated  in  the  13ook  of  Numbers  (chap,  xi.),  that  the  children  of  Israel, 
in  going  through  the  wilderness, longed  for  the  leeks,  garlic,  and  onions  upon 
which  they  bad  led  in  Egypt,  whilst  Herodotus11  tells  us  that  not  less  than 
one  thousand  six  hundred  talents  were  paid  for  radishes,  onions,  and  garlic 
consumed  by  the  workmen  employed  in  erecting  one  of  the  pyramids.  In 
Rome,  garlic  (scorned  by  Horace12  as  only  fit  for  the  "dura  messorum  ilia") 
was  also  employed  as  a  condiment,  and  the  well-known  proverb,  "  fit's  xpe^^ 
edvaros"  proves  thai  iii  Greece  cabbages  must  have  formed  the  most  plebeian 
fare  (Curran).  So  favorable  a  climate  and  such  dietetic  customs  would  not 
afford  the  same  opportunities  for  observing  the  disease  as  the  cold,  inhos- 

1   I'rorrbeticorum  lib.  ii.  2  Liber  do  internis  afl'ectionibus. 

s  De  medicina,  HI),  ii.  cap.  vii. 

1   !><•  causis  et  si^nis  diutumorum  morbnrum,  lib.  i.  cap.  xiv. 

6  Morborum  cbronicorum  lib.  iii.  cap.  iv. 

6  De  re  medica,  lib.  iii.  cap.  xlix.  7  Canonis  medicinre  lib.  iii.  fen  xv.  tract,  i.  cap.  v. 

8  Naturalia  historise  lib.  xxv.  cap.  iii.         9  Geographicorum  lib.  xvi. 

10  De  medicamentis,  cap.  xi.  "  Hist.  lib.  ii.  Euterpe,  cap.  exxv. 

u   Epodoil  lib.,  carin.  iii. 


HISTORY   OF   SCURVY.  279 

pitable,  and  unfertile  fields  of  the  Northmen,  where  the  difficulties  of  pro- 
curing abundant  and  varied  food  would  be  greatly  enhanced,  and  where,  as 
gardens  were  not  cultivated,  the  people  lived  on  salted  or  smoke-dried  meats 
and  fish.  This  rarity  of  horticulture  finds  illustration  in  the  fact  recorded 
by  Hume,  that  Catherine  of  Arragon,  Queen  of  Henry  VIII.,  sent  a  mes- 
senger all  the  way  to  the  Netherlands  for  the  materials  of  a  salad. 

Following  the  current  of  history,  a  long  period  intervenes  in  which  not  a 
vestige  can  be  found  to  indicate  the  occurrence  of  scurvy  (unless  we  accept 
the  rather  doubtful  story  of  the  Xorman  hero  Thorstein,  who  with  a  number 
of  his  fellows  was  supposed  to  have  been  destroyed  by  this  disease  in  an  expe- 
dition to  Greenland  in  1002)  until  the  thirteenth  century,  when  the  religious 
agitation  in  Christian  Europe  led  to  attempts  to  rescue  the  Holy  Land  from 
the  hands  of  the  infidel.  Hordes  of  undisciplined  people,  as  well  as  regularly 
organized  forces,  then  assembled  for  the  invasion  of  Egypt  and  Syria.  The 
lack  of  discipline,  fatiguing  marches,  exposure  to  climatic  vicissitudes,  imper- 
fect quality  and  quantity  of  the  water  supply,  uncleanly  camps,  and  depress- 
ing moral  emotions  from  defeat,  furnished  the  necessary  conditions  for  the 
development  of  scurvy,  and  enormous  loss  of  life  followed.  The  first  and 
fullest  accounts  were  given  by  Jacob  de  Vitry,  who  describes  the  sufferings 
of  the  troops  under  Count  Saarbriicken,  lying  before  Damietta  during  the 
years  1218-19,  after  an  overflow"  of  the  Xile,  accompanied  by  heavy  rains  and 
the  cold  weather  of  December.     He  says : — 

Invasit  prreterea  multos  de  exercitu  qusedam  pestis,  contra  quam  pbysici  nullum  ex 
arte  sua  remedium  invenire  poterant ;  dolor  repentinus  pedes  invasit  et  crura,  et  con- 
junctim  caro  corrupta  gingivas  et  dentes  abducit,  mastieandi  potestatem  auferens  ;  tibias 
horribilis  nigredo  obfuscavit,  et  sic  longe  tractu  doloris  afflieti  cum  patientia  multa 
migraverunt  ad  Dominum  plurimi ;  quidam  usque  ad  vernale  tempus  durantes,  beneficio 
caloris  evaserunt  liberati. 

A  still  more  terrible  epidemic  afflicted  the  army  of  Louis  IX.,  besieging 
Damietta  in  1249,  and  was  graphically  described  by  Jean,  Sire  de  Joinville.1 
The  disease  was  attributed  to  the  nature  and  scarcity  of  the  army's  food, 
which  was  chiefly  fish,  and  to  the  character  of  the  water;  and  it  increased, 
says  the  historian,  "  to  such  a  degree  in  our  camp  as  to  cause  large  masses  of 
dead  flesh  to  spring  from  the  gums  of  our  people.  The  barbers  were  forced 
to  cut  away  the  dead  flesh  to  enable  the  patients  to  eat ;  the  flesh  of  our  legs 
shrunk  up,  and  the  skin  was  covered  with  red  and  black  spots.  Bleeding 
at  the  nose  was  a  sign  of  approaching  death." 

Another  gap,  running  over  the  period  of  nearly  two  centuries,  and  marked 
by  total  silence  as  regards  scurvy,  succeeded ;  Fabricius2  was  the  first  to 
relate  the  occurrence  in  1446,  in  the  north  of  Europe,  of  a  new  and  unheard- 
of  disease  presenting  scorbutic  symptoms,  which  proved  extremely  fatal  at 
various  places  in  Norway,  Sweden,  Siberia,  Russia,  and  Germany.  The  social 
and  material  condition  of  the  masses  of  the  people  was  of  the  most  deplor- 
able character;  they  inhabited  foul,  overcrowded, and  closely-built  dwellings, 
which  exposed  them  to  the  worst  consequences  of  impure  air  and  bad  drain- 
age, while  poverty  added  the  ills  of  scant  and  improper  food,  and  the  rigorous 
effects  of  exposure  to  atmospheric  vicissitudes.  Although  the  districts  bor- 
dering on  the  Xorth  and  Baltic  Seas  were  more  particularly  affected  by  these 
evils,  yet  the  largest  cities  then  presented  a  squalid  aspect  in  striking  con- 
trast with  the  present  spacious  avenues,  gardens,  and  imposing  structures 
everywhere  seen.     Voltaire  states  that,  about  the  year  1500,  industry  had 

1  Histoire  de  St.  Louis  IX.,  par  le  Sire  de  Joinville.     Paris,  1761. 
8  Annales  urbis  Misnicae. 


280  SCURVY. 

not  yet  changed  those  huts  of  wood  and  plaster  of  which  Paris  was  composed, 
into  sumptuous  palaces.  London  was  still  worse  built,  the  Strand  being 
composed  of  mud  walls  and  thatched  houses.  These  wretched  hovels 
swarmed  with  people  until  after  the  great  tire  of  1666,  when  the  houses 
were  less  crowded,  one  person  occupying  as  much  space  as  two  in  the  old 
citv.  Yet,  with  this  amelioration,  the  deaths  from  scurvy  between  the  years 
1671  and  1686,  were  9451.  For  the  period  from  1686  to  1701,  there  were 
1569  deaths,  and  only  226  between  1701  and  1776.  This  remarkable  decrease 
took  place  pari  passu  with  hygienic  improvements  both  in  the  dwellings  and 
food  of  the  people. 

The  earliest  account  of  the  disease  occurring  at  sea,  is  that  related  of  a 
Venetian  merchantman  during  a  voyage  to  Norway  in  1431.  A  little  later 
(1497),  the  crew  of  Yasco  da  Gama,1  in  a  voyage  to  India,  experienced  the 
most  frightful  sufferings  from  this  cause,  so  that — 

"  The  livid  gums  with  growth  prodigious  swelled 
Breathing  infection  that  depraved  the  breeze."2 

The  sixteenth  century  was  marked  by  frequent  epidemics  at  various  points 
in  Europe  and  in  North  America,  and  during  long  voyages,  and  the  disease 
was  alluded  to  by  numerous  writers.  Thus  Euricius  Cordus3  in  his  Botanolo- 
gicon,  published  in  1534,  states  that  the  herb  Chelidonius  minus,  called  by  the 
Saxons  Scarbock  crout,  is  an  excellent  remedy  for  the  disease,  and  the  same 
fact  is  also  alluded  to  by  Julius  Agrieola4  in  his  work  Medicina  Herbaria, 
published  in  1539.  Jacques  Cartier5  relates  in  an  account  of  his  second  voy- 
age, in  1535,  that  an  epidemic  of  scurvy  broke  out  among  the  natives  of 
Stadacona,  in  the  month  of  December,  and  also  affected  the  people  of  his 
ships,  so  that — 

"By  the  middle  of  February,  of  110  persons  there  were  not  ten  whole.  Some  did 
lose  all  their  strength  and  could  not  stand  on  their  feete  ;  then  did  their  legges  swel, 
their  sinnowes  shrinke  as  black  as  a  cole.  Others  also  had  all  their  skins  spotted  with 
spots  of  blood  of  a  purple  colour ;  then  did  it  ascend  up  to  their  ankels,  knees,  thighes, 
shoulders,  armesand  neckes  ;  their  mouths  became  stinking,  their  gummes  so  rotten  that 
all  the  flesh  did  fall  off,  even  to  the  rootes  of  the  teeth,  which  did  also  almost  all  fall 
out." 

He  learned  from  a  native  the  virtues  of  a  decoction  of  the  bark  and  leaves 
of  a  tree  called  hanneda  (probably  the  American  swamp  spruce),  the  use  of 
which  cured  his  men. 

The  frequency  of  events  analogous  to  the  foregoing,  both  on  shipboard  and 
on  land,  invested  the  subject  of  scurvy  with  an  interest  and  an  importance 
that  could  not  fail  to  lead  to  a  more  thorough  investigation  into  its  nature 
and  causes.  The  first  special  treatise  was  published  by  Echthius,6  a  physi- 
cian of  Cologne,  in_1541,  in  which  he  presented  a  fair  summary  of  the  phe- 
nomena of  the  disease  as  he  had  seen  it,  and  differentiated  it  from  other 
bathe-logical  conditions  with  which  it  had  up  to  that  time  been  confounded, 
lie  attributed  the  disease  to  alterations  in  the  blood,  and  not  to  those  of  the 
S], I,. en  or  other  viscera,  as  had  been  erroneously  done  by  his  predecessors. 
Olaus  Magnus,7  in  liis  history  of  the  northern  nations,  bearing  date  1555, gives, 
;1,  of  one  of  the  diseases  peculiar  to  them,  a  Lengthy  description  of  scurvy, 
vulgarly  called  Scharbock;  ascribes  its  origin  to  the  character  of  the  food;  and 

'  Haklnyt  Society's  Publication,  p.  72. 

2  Camoens,  The  Luaiad  ;  Canto  V.  3  Botanologicon.     Colon.  1534. 

<  Medicina  herbaria.     Basil.  1539. 

■•  Hakluyt,  Principal  Navigations,  etc.     London,  1598. 

e  ]),-  Bcorbuto  epitome.    Wittbg.  1585.  7  Hist,  de  gentibus  septent.     Romne,  1555. 


HISTORY    OF   SCURVY.  281 

recognizes  its  more  frequent  occurrence  during  famines  and  sieges :  "  est 
enim  morbus  castrensis,  qui  vexat  inclusos  et  obsessos." 

Two  of  the  most  important  treatises  were  by  contemporaries  of  Echthius, 
both  based  upon  actual  observation  of  the  disease  as  it  occurred  in  Holland. 
One  was  written  by  Ronsseus,1  in  1564,  and  the  other  by  "Wierus,2  in  1567. 
The  former  fell  into  the  error  of  attributing  the  disease  to  splenic  disorder. 
He  regarded  its  prevalence  in  Holland  as  due  to  the  peculiar  damp  air  of  the 
country,  the  use  of  impure  water,  and  the  perpetual  diet  of  sea-birds  and  salt 
meats.  Allusion  is  also  made  to  the  fact  that  seamen  on  long  voyages  cured 
themselves  of  the  disease  by  eating  oranges.  On  the  other  hand,  AVierus 
adopted  the  views  of  Echthius  as  to  the  nature  of  the  disease,  and  rightly 
attributed  its  cause  to  dietetic  errors,  and  recommended  for  its  cure  the 
expressed  juices  of  antiscorbutic  herbs,  or  fresh  herbs  boiled  in  cows'  or 
goats'  milk,  or  whey.  He  regarded  the  disease  as  peculiar  to  the  inhabitants 
of  the  countries  bordering  on  the  North  Sea,  and  had  never  seen  it  in  Spain, 
France,  or  Italy,  nor  in  Asia  or  Africa.  The  treatise  of  AVierus  was  the 
standard  authority  until  the  end  of  the  sixteenth  century.  The  publications 
that  followed  —  the  chief  of  which  were  those  of  Langius,3  Lommius, 
Dodonreus,4  Brucseus,5  Albertus,6  and  Forestus7 — added  little  if  anything  to 
the  information  therein  contained,  but  at  the  same  time  they  rendered  service 
by  disseminating  the  knowledge  already  gained  of  the  disease  in  those  coun- 
tries— Holland,  Flanders,  Brabant,  etc. — where  it  was  habitually  present,  and 
often  epidemic. 

The  most  ample  opportunities  were  furnished  during  the  seventeenth 
century  for  the  attainment  of  correct  notions  of  the  nature  and  causes  of 
scurvy,  by  the  frequent  wars  and  sieges  on  land,  and  by  the  maritime  adven- 
tures and  naval  operations  afloat.  Among  the  most  memorable  may  be  noted 
the  recital  of  Van  der  Mye,8  of  the  suffering  of  the  garrison  of  Breda  during 
the  siege  by  the  Spaniards  in  1624.  The  soldiers  and  the  inhabitants  of  the 
town  were  generally  affected,  1608  of  the  former  having  been  attacked  by 
the  disease  up  to  the  fourth  month  of  the  siege,  and  the  numbers  increasing 
daily  until  the  place  surrendered  in  the  following  June,  after  an  investment 
of  eight  months.  The  weather  had  been  very  wet,  and  the  sufferers  had 
been  compelled  to  live  on  rye  thirty  years  old,  on  cheese,  and  on  dried  fish. 
After  the  fall  of  the  fortress,  and  the  return  of  warm  weather,  the  disease 
disappeared  with  the  use  of  better  food  and  a  supply  of  vegetables.  On  the 
sea,  the  disease  was  rife  everywhere.  Sir  R.  Hawkins9  relates,  in  the  account 
of  his  voyage  to  the  South  Sea  in  1593,  that,  during  his  twenty  years  of 
service  afloat,  upwards  of  10,000  mariners  had  died  of  scurvy  under  his  own 
observation.  And,  in  1609,  three  of  the  four  ships  that  left  England  to 
establish  the  East  India  Company,  lost  nearly  a  fourth  of  their  men  by  the 
time  that  they  arrived  at  the  Cape  of  Good  Hope ;  while  the  fourth  ship,  the 
Commodore's,  escaped  almost  entirely,  in  consequence  of  the  men  having 
been  served  each  with  a  daily  allowance  of  lemon-juice.  On  other  occasions, 
the  mortality  of  the  East  India  Company's  ships  amounted  to  half  of  their 
effective  force,  and  this  devastation  continued  as  late  as  1775,  when  the 
hygienic  reforms  that  had  been  introduced  from  time  to  time  culminated  in 
a  better  state  of  affairs,  so  that  one  ship  made  the  entire  voyage  with  the  loss 
of  but  one  man. 

1  De  magnis  lienibus,  etc.     Antuerp.  1564.  2  Obsorvationes  med.     Basil.  1567. 

3  Medicinal,  epist.  misc.  *  Medic,  observationes,  etc.     Lugd.  1585. 

6  De  scorbuto  propositiones.     Rostock,  1589.  6  Scorbuti  liistoria.     Wittbg.  1594. 

7  Obs.  et  curat,  medic.  8  De  morbis,  etc.,  1627. 
9  Hakluyt  Society's  Publication. 


282  scurvy. 

Scurvy  appeared  in  1631  in  the  Swedish  Army  at  Nuremberg,1  and  again 
in  1633  in  Augsburg,  and  at  the  close  of  the  century  (1699)  at  the  Hotel 
Dieu,  Paris.  These  examples  serve  to  show  how  little  advantage  had  been 
taken  of  the  knowledge  already  gained  of  the  causative  influences  determin- 
ing the  disease.  In  tact,  the  treatises  that  appeared  at  this  time  were  inferior 
to  those  of  the  preceding  century,  and  the  most  notable  example  was  the 
book  of  Engalenus,2  published  in  1604,  which,  from  the  great  esteem  in 
which  it  was  held  for  more  than  a  century,  served  to  disseminate  the  most 
absurd  views  concerning  the  pathology  of  scurvy.  Scarcely  an  ailment  was 
attributed  to  other  than  scorbutic  influences,  and  certain  peculiarities  of  the 
pulse  and  urine  were  regarded  as  the  most  certain  and  characteristic  signs  of 
their  presence.  This  confusion — created  first  by  Engalenus,  and  further 
extended  by  other  writers  who  had  adopted  his  opinions,  such  as  Sennertus,3 
"Willis,4  and  Lister5 — induced  not  a  few  to  doubt,  and  even  to  deny,  the 
existence  of  scurvy  as  a  distinct  affection. 

The  eighteenth  century,  however,  furnished  the  most  marked  examples  of 
the  devastation  produced  by  scurvy,  commencing  with  the  siege  of  Thorn6  by 
the  Swedes,  in  1703,  in  which  5000  of  the  garrison,  besides  many  of  the 
inhabitants,  were  destroyed  by  the  disease,  while  the  besiegers  were  abso- 
lutely exempt  from  it.  When  the  investment  ended,  and  succulent  vegetables 
were  permitted  to  enter  the  town,  the  disease  quickly  disappeared.  It  also 
occurred  in  Cronstadt,7  Viborg,  and  St.  Petersburg,8  between  1731  and  1738, 
when  thousands  of  common  soldiers  were  cut  off,  but  not  a  single  officer 
suffered.  The  disease  was  so  widespread  and  fatal  that  Kramer,9  physician 
to  the  army,  requested  a  consultation  of  the  College  of  Physicians  of  Vienna. 
Their  advice  was,  however,  of  no  avail,  for  the  disease,  which  had  broken 
out  at  the  end  of  winter,  continued  until  the  approach  of  summer,  when 
succulent  vegetables  were  procurable.  Of  four  hundred  cases  treated  with 
calomel,  every  one  died.  At  the  siege  of  Azof,10  in  1736,  the  Prussians  suf- 
fered severely,  as  did  also  the  Russian  Army,  in  1742,  at  Viborg  and  other 
places.  The  malady  was  greatest  during  the  winter  and  spring,  and  was 
ascribed  to  the  unwholesome  character  of  the  food,  and  the  want  of  fresh 
succulent  vegetables.  The  dreadful  misfortune  of  Admiral  Hosier,  who 
commanded  the  English  fleet  in  the  West  Indies  in  1728,  presents  an  example 
of  tragic  interest :  he  lost  two  crews  from  the  disease,  and  in  consequence 
died  himself,  broken-hearted ;  and,  a  little  later,  the  fleet  of  Admiral  Rodney, 
on  the  same  station,  suffered  severely.  In  1740,  Lord  Anson  left  England 
with  a  squadron  to  circumnavigate  the  globe,  and,  after  the  most  harroA\  ing 
experiences  from  tempest  and  scurvy,  returned  with  less  than  a  fifth  of  his 
original  force.  The  disease  was  fatally  rife,  though  the  men  were  abundantly 
supplied  with  fresh  animal  food.  The  fleet  under  the  command  of  Admiral 
Geary,  in  1780,  returned  to  England  with  2400  cases  of  scurvy,  and  the 
Channel  fleet  under  Lord  Howe  was  completely  disabled  from  the  same 
cause 

In  1749-50,  the  disease  reigned  in  Friesland,  and  at  Riga,  P>reslau,  and 
Venice;  and  the  British  troops,  5000  in  number,  as  related  by  Smollett,11  were 
at  the  siege  of  Quebec,  in  1760,  so  distressed  by  want  of  vegetables  and  the  ex- 
cessive cold,  that  before  the  end  of  April  1000  men  died  of  scurvy,  and  more 

i  Rotenbeck  et  Horn,  Specnl.  scorbuti.     Norimb.  1(533. 

2  De  morbi  scorbuto,  1(504.  s  Tractatus  de  scorlmto.     Wittbg.  1(524. 

4  Tractates  de  Bcorbuto,  1(5(57.  6  Tractatus  de  quibusdarn  morbis,  etc.,  1699. 

6  Bachstrom,  Observat.  circa  scorbut.,  1734.         7  Sinopeus,  Parerga  medica.     Petersb.  1734. 

8  Nitzsch,  Abhandlung  des  Scharbocks.     Petersb.  1747 

9  Medicina  castrenais.     Norimb.  t73.r>. 

10  A.  Nitzsch,  TheoretiBch-practiache  Abhandlung  des  Scharliockes. 

11  History  <>f  England. 


HISTORY   OF   SCURVY.  283 

than  twice  that  number  were  rendered  unfit  for  service.  Though  the  course 
of  this  century  was  marked  by  these  lamentable  occurrences  on  land  and  at 
sea,  yet  slow  but  steady  hygienic  improvements  were  discernible.  The  most 
eminent  example  of  intelligent  appreciation  of  their  importance  was  that  of 
Captain  Cook,  in  a  voyage  of  circumnavigation  in  1772-75,  which  was  accom- 
plished with  the  loss  of  but  a  single  man.  This  result  was  obtained  by  minute 
attention  to  the  dryness,  cleanliness,  and  ventilation  of  the  ship,  and  by  the 
use  of  suitable  food.  This  example  was  not  lost,  for  although  the  anti-scor- 
butic influence  of  fresh  vegetables  and  fruits  had  long  been  a  familiar  fact, 
yet  it  was  not  until  1795  that  the  use  of  lemon-juice  was  made  an  integral 
portion  of  the  ration  of  the  British  Navy  by  official  order.  The  hygienic 
condition  of  that  service  has  gradually  improved  since  this  period,  so  that 
scurvy  has  been  well-nigh  banished.  These  ameliorations  have  been  chiefly 
due  to  the  labors  and  writings  of  James  Lind  and  Sir  Gilbert  Blane,  the 
observations  of  the  former  having  been  printed  in  1749,  and  those  of  the 
latter  in  1785,  and  both  having  gone  through  several  editions. 

The  nineteenth  century  has  been  marked  by  notable  progress  in  hygienic 
knowledge,  and  scurvy  has  become  restricted  to  narrower  limits  and  to  excep- 
tional occurrences.  At  the  siege  of  Alexandria,  in  1801,  which  was  com- 
menced in  May  and  ended  in  August,  and  which  furnished,  according  to 
Larrey,  the  conditions  for  an  outbreak  of  the  disease,  viz.,  cold,  dampness, 
and  bad  food,  3500  cases  were  admitted  into  the  military  hospitals  of  the 
city,  and  many  died.  The  disease  was  finally  controlled  by  the  issue  of  vine- 
gar, dates,  coffee,  and  syrup.  The  officers,  who  were  well  rationed,  did  not 
sutler.  In  1809,  the  United  States  troops  encamped  in  the  Lower  Mississippi, 
lost  over  600  men  from  the  disease.  The  army  of  Ibraheem  Pasha,  in  Arabia, 
was  so  sorely  beset  by  scurvy,  that  out  of  an  army  of  over  100,000  men  few 
returned  to  their  homes,  on  account  of  insufficient  food,  harassing  marches, 
and  fatigue.  The  English  troops  in  the  war  in  Siam  and  Ava,  supplied  a 
large  quota  of  cases  of  scurvy,  and  of  scorbutic  dysentery  and  ague  ;  and  in 
1837,  in  the  Caffir  war,  they  were  severely  afflicted,  for,  although  they  were 
abundantly  supplied  with  good  fresh  meat,  they  had  long  been  without  fresh 
vegetables  and  fruits.  A  similar  experience  occurred  in  the  Punjaub,  in 
1848-49. 

Scurvy  had  been  seldom  or  never  seen  in  Great  Britain  from  the  end  of  the 
last  century  up  to  1847,  except  in  jails  and  penitentiaries,  as  at  Millbanke  in 
1823  ;  but  in  the  early  months  of  1847  and  1848,  it  made  its  appearance  in 
many  places,  owing  chiefly  to  the  potato  blight  which  destroyed  the  usual 
food  supply.  At  this  time  the  most  terrific  devastation  from  scurvy  was 
reported  in  several  of  the  Russian  provinces.  The  total  number  of  cases  was 
estimated  at  260,444  of  which  67,958  proved  fatal. 

Dr.  Gale1  reported  the  sufferings  of  the  American  troops  in  1820,  in  their 
march  to  Council  Bluffs,  which  place  was  reached  in  October  after  weeks  of 
the  greatest  hardships  in  navigating  the  boats  up  the  Missouri  River,  during 
which  time  the  men  were  exposed  to  the  midday  sun,  evening  dews  and  chilly 
nights,  with  food  consisting  chiefly  of  salted  or  smoke-dried  meats,  without 
vegetables  or  groceries  of  any  sort.  In  the  following  January,  scorbutic  cases 
began  to  show  themselves,  but  the  disease  proved  fatal  to  few  until  February. 
when  nearly  the  whole  regiment  sank  beneath  its  influence,  and  it  continued 
unabated  until  April  when  wild  vegetables  appeared.  The  strength  of  this 
post  and  of  that  at  St.  Peter's,  was  1016  ;  the  number  of  cases  506  ;  and  the 
number  of  deaths  168.  But  one  officer  was  affected,  and  the  hunters  who 
lived  in  the  woods  and  subsisted  on  game  were  in  no  instance  unhealthy.    The 

1  Forry,  American  Journal  of  the  Medical  Sciences,  N.  S.,  vol.  iii.  p.  77. 


284  scurvy. 

United  States  forces1  also  suffered  to  some  extent  in  the  Florida  and  Mexican 
wars.  Among  the  troops  in  Texas,  between  the  years  1849  and  1854,  of  an 
aggregate  force  of  4450,  510  cases  of  scurvy  occurred,  of  which  three  proved 
fatal.  The  disease  was  due  to  the  frequent  movements  of  the  troops,  and  to 
the  fact  that  the  sandy  and  sterile  nature  of  the  soil  in  the  vicinity  of  some  of 
the  posts  offered  insurmountable  obstacles  to  the  cultivation  of  gardens.  The 
disease  also  prevailed  at  posts  in  the  northwestern  territory.  Dr.  Day 
remarks  that  during  the  winter  of  1848-49,  the  disease  appeared  among  the 
Indians.  Their  diet  was  poor  and  insufficient,  but  the  scorbutic  tendency 
among  them  was  not  nearly  as  great  as  among  the  whites ;  their  powers  of 
digestion  and  assimilation  (when  they  have  anything  to  digest  and  assimi- 
late) being  certainly  better  than  those  of  almost  any  other  people.  Dr.  Coale2 
reports  the  occurrence  of  scurvy  in  1838,  among  the  crew  of  the  United 
States  ship  Columbus,  in  a  cruise  around  the  world.  The  ship  left  Norfolk, 
Virginia,  in  January,  1838,  with  a  crew  broken  down  in  health,  and,  after 
leaving  Rio,  smallpox  ran  through  the  vessel.  Off  the  Cape  of  Good  Hope, 
a  few  weeks  later,  during  a  spell  of  cold  weather  in  which  the  decks  were 
almost  continually  kept  wet,  the  first  cases  of  scurvy  appeared  ;  and  others 
continued  to  appear  until  January,  when  the  ship  reached  the  East  Indies, 
where  dysentery  first,  and  afterwards  diarrhoea,  were  added  to  the  miseries  of 
the  crew.  Dr.  Coale  remarks  that  the  most  fatal  cases  occurred  among  the 
most  vigorous  men ;  there  were  three  cases  of  lryctalopia.  The  provisions 
served  out  contained  Only  the  ordinary  navy  ration,  defective  in  fresh  vege- 
tables. Dr.  Foltz3  gives  the  history  of  an  outbreak  of  scurvy  in  the  United 
States  squadron  cruising  in  the  Gulf  of  Mexico,  during  the  summer  of  1846. 
On  board  the  Potomac,  with  a  crew  of  500  souls,  350  were  disabled,  and  symp- 
toms of  the  disease  were  present  in  most  of  those  who  remained  on  duty. 
The  other  ships  suffered  to  a  greater  or  less  extent,  particularly  those  that 
had  been  long  in  commission  in  the  West  Indies.  The  Mississippi,  a  steamer, 
made  short  passages  at  sea,  and  the  crew,  being  enabled  to  procure  fresh  vege- 
tables, suffered  only  to  a  trifling  extent.  In  the  British  Navy,4  between  the 
years  1837  and  1843,  there  were  93  cases  of  scurvy  returned  from  the  East 
India  squadron,  5  from  the  east  coast  of  Africa,  13  from  the  West  Indies,  and 
for  the  other  squadrons  a  still  smaller  number.  Since  that  time  the  disease 
has  had  but  a  nominal  existence. 

The  allied  armies  of  England,5  France,  Sardinia  and  Turkey,  during  the 
Crimean  war  of  1854-56,  underwent  hardship  and  suffering  of  the  most 
aggravated  description,  from  vicissitudes  of  weather,  physical  fatigue,  and 
deprivation  of  wholesome  food  and  vegetables.  The  result  was  that  in  the 
British  army  there  were  reported  during  the  whole  period,  2096  cases  of 
frankly  expressed  scurvy,  while  the  taint  was  widespread,  complicating  other 
diseases,  such  as  diarrhoea,  dysentery,  and  malarial  fevers,  and  greatly  exagge- 
rating their  mortality,  especially  during  the  first  six  months  of  the  siege.  Of 
the  total  number,  178,  or  8.4  percent.,  died,  the  mortality  having  been  almost 
entirely  confined  to  the  winter  and  spring  of  1854-5.  The  disease  began  in 
October,  1854,  gradually  increasing  during  the  following  year,  1855,  and  in 
February  reached  its  height,  viz.,  641  admissions.  From  this  time  it  gradu- 
ally subsided,  so  thai  by  August  the  admissions  were  only  three.  In  Septem- 
ber of  the  same  year  it  again  increased,  until  January,  1856,  when  it  reached 
its    maximum,   and    then    again   it   rapidly  declined.      The   increased   and 

•  Statistical  Report  of  the  U.  B.  Army,  1839-54,  p.  369. 

2  Americas  Journal  of  the  Medical  Sciences,  N.  S.,  vol.  iii.  p.  G8. 

3  Ibid.,  p.  59. 

*  Statistical  Report  of  the  Health  of  the  Navy. 

5  Medical  and  Surgical  History  of  the  British  Army,  1854-50". 


ETIOLOGY   OF   SCURVY.  285 

decreased  prevalence  noted,  exactly  accorded  with  the  character  of  the  food 
supply  as  to  quality  and  quantity.  In  the  early  part  of  the  war,  this  was  of 
the  most  wretched  kind ;  afterwards  the  greatest  improvements  were  made, 
and  with  the  most  satisfactory  results.  The  French  fared  even  worse  than 
the  English  forces,  as  regarded  their  supplies,  and  the  consequence  was  the 
rapid  appearance  of  the  disease,  so  that  20,000  cases  were  reported ;  yet  for 
the  month  of  February,  1855,  fresh  meat  of  good  quality,  though  lean,  was 
issued,  at  first  twice  and  afterwards  five  times  a  week  ;  there  was  an  irregular 
supply  of  bread,  but  rice  was  occasionally  allowed,  with  dried  vegetables  such 
as  peas  and  beans.  With  the  opening  of  spring  and  the  growth  of  vegeta- 
tion, especially  dandelion,  which  the  men  procured  for  food,  the  disease  abated 
only  to  be  renewed  in  the  following  July,  when  the  hot,  dry  weather  destroyed 
the  greens  attainable  earlier  in  the  year.  The  Sardinian  and  Turkish  forces 
suffered,  if  anything,  still  more  severely  than  their  English  and  French  allies. 
During  the  war  of  the  Rebellion,  1861-65,  both  the  United  States  and  the 
Confederate  forces  occasionally  suffered  from  scurvy,  or  from  its  influence  in 
other  diseases.  The  cases  of  scurvy  occurring  in  the  various  naval  services, 
are  isolated  and  infrequent,  in  consequence  of  the  rigid  hygienic  measures  now 
adopted.  It  has  not  been  banished  from  the  mercantile  marine  as  it  should  be, 
yet  the  condition  of  the  men  in  this  service  has  been  greatly  improved  by  wise 
legal  enactments.  Since  the  passage  of  the  Shipment  Act,  in  Great  Britain, 
in  1867,  scurvy  has  decreased  about  70  per  cent.  The  "Dreadnought"  Hos- 
pital-ship1 still  continues  to  receive  annually  an  average  of  90  cases,  or  about 
one  twenty-fifth  of  all  the  cases  admitted,  due  to  the  issue  of  improper  food, 
or  of  rations  defective  in  vegetable  matter  and  acid  juices.  According  to  the 
report2  of  the  U.  S.  Marine  Hospital  Service,  there  were  admitted  in  1873,  47 
cases;  in  1874,  59  cases;  and  in  1875,  25  cases;  an  average  of  nearly  44  for 
each  of  those  years.  The  latest  record  of  the  general  occurrence  of  scurvy 
was  during  the  siege  of  Paris  by  the  Germans,  in  1872,  from  the  usual  cause 
— food  deficient  in  fresh  vegetable  material. 

Etiology  of  Scurvy. 

Scurvy  has  no  geographical  limitation.  It  has  prevailed  in  the  extreme  high 
latitudes  of  both  the  northern  and  southern  frigid  zones,  on  vessels  engaged 
in  arctic  explorations,  and  among  the  native  Laplanders  and  Esquimaux; 
almost  everywhere  within  the  temperate  zones,  m  the  eastern  and  western 
continents ;  and  on  numerous  occasions  both  ashore  and  afloat  in  torrid  re- 
gions3 of  the  equator.  It  affects  alike  all  races,  the  Caucasian,  Malay,  Negro, 
and  Indian.  Xor  has  it  been  confined  to  mankind,  for  at  least  one  authentic 
case  has  been  recorded  by  Berenger-Feraud,4  of  a  Gorilla  having  suffered  from 
scurvy.  All  classes  of  society,  rich  and  poor,  high  and  low,  are  equally  liable, 
whenever  surrounded  by  circumstances  that  preclude  the  attainment  of  the 
requisite  nutriment. 

The  disease  has  been  observed  at  all  ages  from  infancy  to  senescence ;  the 
orphan  asylum  at  Moscow  was  invaded,  alike  with  the  asylum  for  the  aged 
at  Christiania.  The  crews  of  affected  ships,  and  the  forces  holding  besieged 
towns  or  fortresses,  have  suffered  without  regard  to  age.     In  epidemics,  and 

1  Scurvy  in  Merchant  Ships,  1865. 

2  Report  of  Supervising  Surgeon-General,  U.  S.  Marine  Hospital  Service,  1876. 

3  The  seasons  exercise  no  control  over  the  occurrence  of  the  disease  other  than  that  arising 
tVoin  their  influence  upon  the  growth  of  vegetation  and  upon  human  health,  through  the  physical 
qualities  of  heat,  cold,  and  dampness.  Of  the  68  epidemics,  referred  to  by  Hirsch,  in  which  the 
season  was  noticed,  37  occurred  in  spring,  21  in  winter,  8  in  summer,  and  2  in  autumn. 

4  Comptes  Rendus,  1S58. 


286  scurvy. 

principally  in  those  occurring  during  famines,  observations  have  been  made 
which  seem  to  indicate  a  partiality  of  the  disease  to  attack  adults.  Curran 
says  that  in  all  of  his  cases  during  the  Irish  famine,  the  age  of  the  patients 
exceeded  eighteen  years,  whilst  at  least  two-thirds  of  the  patients  were  beyond 
the  middle  period  of  life  ;*  a  circumstance  that  might  easily  be  explained  by 
the  difference  in  the  degrees  of  exposure,  at  different  ages,  to  the  determining 
causes  of  the  disease.  Nor  would  the  youthful  portion  of  a  community  be  apt 
to  be  exposed  in  the  same  degree  to  the  disturbing  influences  of  tempestuous 
weather,  exhausting  labors,  and  depressing  emotions.  Old  age  brings  with 
it  mal-nutrition  and  debility  that  invite  the  speedy  invasion  of  morbific 
causes. 

Sex  cannot  be  accused  of  any  predisposing  influence  :  statistical  returns  will, 
of  course,  show  an  excess  of  males,  for  the  reason  that  they  are  more  often 
under  those  conditions  which  determine  the  disease.  It  has  occasionally  hap- 
pened, however,  that  more  women  than  men  have  been  attacked,  as  in  the 
epidemic  of  1813  in  Southeastern  Hungary;  and  in  Croatia,  in  1707,  women 
only  were  affected.  In  the  Irish  famine,  the  proportion  was  about  eleven 
males  to  one  female. 

It  has  been  surmised  that  a  low  temperature,  particularly  when  associated 
with  dampness,  fatigue,  and  mental  depression,  was  a  powerfully  predisposing 
cause,  if  it  did  not  actually  originate  the  disease.  M.  Scoutetten,2  in  a  com- 
munication to  the  Aeademie  de  Medecine  on  the  epidemic  at  Giret,  insisted 
upon  these  influences  as  all-powerful — an  opinion  which  seemed  to  be  sus- 
tained by  the  Academy.  The  Austrian  war  ship  Xovara,  in  her  passage  from 
Madras  to  Singapore,  although,  it  is  represented,  abundantly  supplied  with 
fresh  vegetables  and  acid  fruit,  was  invaded  bjr  scurvy.  The  disease  also  oc- 
curred at  Rastadt,3  among  the  Austrian  troops,  when,  according  to  Opitz,the 
only  assignable  causes  were  dampness  and  cold,  the  food  not  being  defective 
in  fresh  vegetables.  So,  at  Ingolstadt,  the  French  prisoners  in  1871  suffered, 
although  abundantly  supplied  with  potatoes  and  meat.  In  opposition  to  these 
views,  it  may  be  stated  that  the  hottest  and  driest  parts  of  the  earth,  as  in 
India,  the  West  Indies,  and  the  interior  of  Africa,  have  been  the  scenes  of  as 
destructive  outbreaks  as  those  regions  where  the  reverse  conditions  hold  good. 
The  greatest  hardships  have  been  undergone,  without  the  slightest  evidence 
of  scorbutic  taint  affecting  the  sufferers,  as  long  as  proper  alimentation  could 
be  maintained.  On  the  other  hand,  inactivity  lias  been  regarded  as  a  predis- 
posing cause,  and  the  alleged  greater  frequency  of  the  disease  among  marines 
and  skulkers  of  war  ships,  than  among  the  seamen,  is  said  erroneously  to  be 
due  to  this  cause. 

Depressing  emotions,  fear,  anxiety,  despair,  etc.,  have  been  said  to  be  able  to 
determine  the  disease,  and  those  of  a  reverse  character  to  be  able  to  check  its 
progress ;  and  our  credulity  is  not  a  little  taxed  when  we  read  the  statement 
of  Lind',  that  he  has  seen  the  scurvy,  very  prevalent  and  increasing  in  the 
fleet,  at  once  arrested  and  quickly  got  rid  of  by  the  news  of  a  successful 
engagement,  <>r  even  the  anticipation  of  one;  or,  more  apochryphal  still,  the 
story  of  the  Prince  of  Orange  having  arrested  the  disease  by  distributing  a 
little  colored  water  which  was  believed  by  the  soldiers  to  be  a  wonderful  and 
most  expensive  elixir.  Monneret,4  Fleury,and  Papavoine,6  have  even  asserted 
that  they  have  seen  scurvy  result  from  mental  influences  alone  in  isolated 
eases. 

1  Dublin  Quarterly  Journal  of  Med.  Science,  1847. 

4  Gazette  MSdicale  de  Paris,  Juillet,  1847. 

n  Vierteljahrsselirift  fur  die  praktisohu  Heilkunde,  Bd.  i.  S.  114. 

4  Compend.  de  M6d.,  t.  vii.  p.  507. 

5  Journal  llebdom.,  t.  ix.  p.  321. 


ETIOLOGY    OF   SCURVY.  287 

Foul  air  has  no  influence  in  determining  the  occurrence  of  scurvy,  except 
in  a  general  way  by  lessoning  the  vital  resistance,  and  thus  hastening  and  in- 
tensifying the  symptoms  of  this,  as  of  any  other  disease  depending  upon  a 
specific  cause.  Personal  tilth  and  foulness  of  the  surroundings  Lave  also  been 
erroneously  held  responsible  for  a  share  in  its  production.  Even  the  pure  air 
of  the  sea  was  at  one  time  thought  to  be  influential  in  exciting  the  disease, 
though  little  reflection  was  necessary  to  dispel  this  absurd  notion.  Scurvy 
has  raged  in  inland  towns  and  on  fresh  water  courses,  far  away  from  the  in- 
fluences of  a  marine  atmosphere.  The  opinion  was  even  held  that  the  cir- 
cumstance  of  locality  determined  a  difference  in  the  nature  of  the  disease, 
and  hence  the  origin  of  the  terms  land  scurvy  and  sea  scurvy;  whereas  the 
fact  is  that  there  is  no  more  pathological  difference  in  these  cases  than  there  is 
in  cases  of  pneumonia  or  typhoid  fever  occurring  on  shore  and  at  sea.  This 
view  has  been  well  nigh  abandoned,  though,  as  late  as  1856,  Dr.  Crawford1 
emitted  the  same  notion  in  relating  his  experience  in  the  Crimea.  He  states 
that  scurvy  seldom  exhibited  there  the  characteristic  features  so  often  ob- 
served at  sea,  viz.,  the  ulcerated  and  gangrenous  gums,  tailing  out  of  the  teeth, 
abscesses  and  sloughing  ulcers,  contraction  of  the  limbs,  visceral  effusions, 
syncope,  and  sudden  death  ;  and  adds  that  it  would  seem  probable  that  the 
difference  between  land  and  sea  scurvy  was  physiologically  connected  with  the 
existence  of  diarrhoea  and  dysentery  in  the  one  case,  and  their  absence  in  the 
other ;  the  affection  as  observed  at  sea  being  usually  attended  with  a  torpid 
or  at  least  irregular  state  of  the  bowels.     This  opinion  is  erroneous. 

In  certain  instances,  the  occurrence  of  scurvy  has  been  supposed  to  be  due 
to  the  use  of  impure  water,  as  in  the  case  of  Ranke's  expedition  to  the  interior 
of  Australia.  There  were  two  parties:  one,  thoroughly  ecpiipped  and  pro- 
visioned, suffered  for  the  want  of  abundant  potable  water,  and  was  attacked 
with  the  disease;  the  other,  less  advantageously  placed  as  regarded  food  and 
provisions,  got  all  the  pure  water  that  they  needed,  and  escaped.  Other 
parallel  cases  are  recorded,  but  they  are  entirely  negative  from  the  lack  of 
certainty  as  to  the  exact  nature  of  the  food  consumed.  The  more  fortunate 
of  Ranke's  party  may  have  partaken  of  succulent  plants  or  esculent  roots 
picked  up  on  the  journey.  The  various  above-mentioned  influences,  whether 
ashore  or  afloat,  are  capable  of  deteriorating  the  nutrition  of  the  body,  and 
may  in  this  way  with  truth  be  chargeable  with  promoting,  under  peculiar 
dietetic  irregularities,  the  advent  of  an  outbreak  ;  but  neither  singly  nor  com- 
binedly  can  they  determine  it  without  this  concomitant. 

Individual  peculiarities  as  to  constitutional  power  and  vital  activity,  exert  a 
marked  influence ;  those  of  a  weakly  habit  of  body,  either  original  or  pro- 
duced by  accidental  attacks  of  disease,  are  more  liable  than  those  in  robust, 
vigorous  health.  Persons  also  who  have  been  overworked  or  exhausted  by 
excessive  climatic  influences,  whether  of  heat  or  cold,  more  readily  succumb. 
This  was  seen  in  the  case  of  two  ships  of  the  United  States,  serving  in  the 
Gulf  of  Mexico :  the  "  Raritan,"  coming  from  the  coast  of  Brazil,  had  a  crew 
enfeebled  by  long  service  in  a  hot  climate,  while  that  of  the  "Falmouth"'  was 
worn  out  by  exposure  to  the  cold,  wet  and  boisterous  weather  of  the  northern 
coast  of  America,  on  which  she  had  been  serving.  Both  of  these  vessels 
suffered  severely.  In  the  same  way,  the  deterioration  of  the  vital  powers 
brought  about  by  an  arctic  voyage  and  a  winter's  residence  in  high  latitudes, 
renders  the  men  exceedingly  liable  in  presence  of  the  exciting  cause  of  scurvy, 
and  more  so  than  those  who  are  freshly  arrived.  There  is  no  such  tiling  as 
inuring  the  system  to  the  unnatural  surroundings  of  the  arctic  regions ;  the 
longer  the  residence  there,  the  more  likely  the  disease  is  to  occur.     This  state- 

1  Med.  and  Surg.  History  of  the  British  Army,  1S54-56. 


288  scurvy. 

ment  is  based  upon  experience,  and  readily  commends  itself  to  the  judgment 
when  the  immense  importance  of  sunlight  upon  the  nutrition  of  the  entire 
organic  world  is  considered.  One  attack  of  scurvy  confers  upon  its  victim  no 
exemption ;  on  the  contrary,  it  renders  a  second  more  probable,  other  circum- 
stances being  equal. 

The  frequent  association  of  the  scorbutic,  with  other  pathological  con- 
ditions, is  well  known,  and  doubtless  forms  one  of  the  chief  reasons  why  the 
early  descriptions  of  the  disease  were  so  inaccurate,  the  complicating  affections 
having  being  included  in  them.  A  frequent  combination  is  with  malarial 
disease,  and  it  is  easily  appreciated  that  the  slow  and  profound  alterations 
induced  in  the  blood  by  this  miasm  are  well  calculated  to  hasten  the  develop- 
ment of  scurvy.  The  same  influence  is  exerted  by  diarrhoea,  dysentery, 
syphilis,  hemorrhages,  exhausting  discharges,  and  the  debility  arising  from 
prolonged  suffering  from  wounds  and  injuries.  In  fact,  any  cause  whatever 
that  lowers  the  tone  of  the  system  and  impairs  nutrition,  may  be  considered 
among  the  category  of  predisposing  causes.  It  will  be  only  necessary,  in 
passing,  to  notice  the  fanciful  idea  of  Travis,1  that  the  use  of  copper  vessels  in 
the  navy  was  a  principal  cause  of  scurvy  ;  or  that  of  Harvey,2  who  attributed 
it  to  gluttony  or  debauchery ;  or  that  of  Maynwaringe,3  that  it  was  due  to 
tobacco  and  excessive  venery ;  or  that  of  "Willis,4  who  found  its  cause  in  the 
increasing  consumption  of  sugar. 

The  evident  connection  between  the  character  of  the  food  supply  and  the 
occurrence  of  scurvy,  attracted  the  attention  of  early  observers,  particularly 
Wierus  and  Echthius,  who  placed  the  cause  entirely  in  errors  of  diet.  This 
was  the  opinion  also  of  Bachstrom,  who  published  an  essay  on  scurvy  in  1734, 
in  which  he  took  the  ground  that  abstinence  from  fresh  vegetables  was  abso- 
lutely the  cause  of  the  disease,  an  opinion  which  was  shared  by  other  writers 
of  experience,  such  as  Eouppe5  and  Trotter.6  This  view  has  largely  prevailed, 
and  is  now  that  which  is  accepted  by  most  physicians.  In  1847,  Dr.  Christi- 
son,7  of  Edinburgh,  in  a  paper  on  the  subject,  attributed  the  prevalence  of 
scurvy  at  Perth  to  deficiency  in  the  quantity  of  azotized  aliment  and  conse- 
quent insufficient  nourishment  of  the  body,  and  asserted  his  belief  that  milk, 
which  supplied  this  deficiency,  was  an  antidote  for  the  disease.  This  theory, 
though  ingeniously  argued,  is  unsupported  by  facts ;  thus,  for  instance,  in  the 
north  of  Wales,  where  fresh  meats  and  milk  are  abundant,  and  where  the 
cottagers  raise  little  or  no  garden  produce,  cases  of  scurvy  appear  every  year; 
and,  indeed,  the  whole  history  of  the  disease  is  at  variance  with  this  theory. 

The  habitual  use  of  salted  meats  on  ship-board,  drew  attention,  naturally 
enough,  to  the  causative  relation  of  this  sort  of  food,  and  not  a  few  of  the 
earlier  observers  have  recorded  their  belief  that  it  was  the  chief,  if  not  the 
only,  cause  of  scorbutic  outbreaks.  This  statement  has  no  foundation,  how- 
ever, for  the  very  worst  epidemics  of  the  disease  have  occurred  at  sea,  when 
fresh  animal  food  has  been  abundant,  and  in  communities  on  shore  who  never 
employ  salt  provisions  of  any  sort  in  their  diet.  The  disease  will  undoubtedly 
appear  more  speedily  in  those  living  on  salt,  than  in  those  living  on  fresh, 
animal  food  ;  but  from  the  mere  fact  that  the  nourishing  power  of  the  latter 
has  been  Impaired  by  the  removal  to  a  greater  or  less  extent  of  its  albuminoid 
constituents  in  the  salting  process,  and  that,  as  a  consequence,  it  possesses  less 
power  in  sustaining  the  body.  The  withdrawal  of  both  sorts  of  animal  food 
would  still  more  speedily,  for  the  same  reason,  lead  to  the  appearance  of  the 
disease.     That  sail    in   itself  is  impotent  as  a  causative  influence,  is  further 

1  Mill.  Obs.  and  Inquiries.     London,  vol.  ii.,  1762.  2  Tlio  Diseases  of  London. 

3  Morbus  polyrrhizos.  4  Tractatus  de  scorlmto. 

6  D«  nii'il. is  navigantium,  1704.  6  Observations  on  the  Scurvy,  1792. 

'  Monthly  Journal  of  Medical  Science,  1847. 


ETIOLOGY   OF   SCURVY.  289 

shown  by  the  fact  that  large  quantities  of  it  may  be  given,  as  was  done  by  Sir 
G.  Blane,  in  scorbutic  cases,  without  apparent  deleterious  effects.  Simple 
deficiency  in  the  quantity  of  the  food  also,  it  has  been  alleged,  plays  the  most 
important  role  in  the  causation  of  the  disease,  and  its  prevalence  during 
famines  has  been  cited  in  evidence  of  the  truth  of  this  assertion.  The  fact  is 
quite  familiar,  however,  that  scurvy  is  far  from  being  an  invariable  accompani- 
ment of  famine,  nor  does  it  affect  men  on  long  cruises,  or  those  shut  up  in 
besieged  towns,  when  simply  on  short  rations. 

The  quality  of  the  food  has  as  little  influence  as  lack  of  quantity  in  pro- 
ducing the  disease.  Mouldy  biscuit,  and  spoiled  or  even  putrid  meats,  have 
been  subsisted  upon  for  long  periods,  and  though  the  health  has  been  thereby 
greatly  impaired,  no  scorbutic  condition  has  been  produced. 

From  all  the  facts,  both  positive  and  negative,  we  may  reasonably  assume 
that  the  essential  dietetic  error  leading  to  the  development  of  scurvy,  in  the 
immense  majority  if  not  in  all  cases,  consists  in  a  deficiency  in  the  variety  of 
food ;  that  is  to  say,  that  there  is  not  the  requisite  proportion  of  animal  mat- 
ter with  a  diversity  of  vegetable  substances.  No  single  natural  order  contains 
plants  that  supply  all  the  substances  essential  to  the  nutrition  of  the  body  and 
right  composition  of  the  blood;  the  graminaceous  and  leguminous  articles  of 
food,  for  instance,  are  numerous  but  not  various;  they  all  afford  the  same  or 
analogous  albuminous  elements  which  have  about  the  same  nutrient  value  aa 
the  corresponding  substances  in  animal  food ;  and  hence  health  and  vigor 
cannot  be  sustained  on  a  diet  of  animal  flesh,  combined  with  wheat,  rice.,  and 
oat-meal,  or  with  beans  and  peas,  or  with  all  of  these  together.  Outbreaks 
of  scurvy  have  occurred  on  ship-board  where  the  ration  is  made  up  princi- 
pally of  these  articles,  as  on  Anson's  ships  when  supplied  with  an  abundance 
of  fresh  animal,  farinaceous,  and  leguminous  foods.  In  the  epidemic  that 
occurred  at  Carlisle  and  its  vicinity,  according  to  Dr.  Lonsdale,1  some  of  the 
railway  excavators  were  affected,  though  they  breakfasted  off  of  beefsteaks 
or  mutton  chops,  and  partook  of  dinners  composed  of  bread,  boiled  beef  or 
bacon,  pea-soup  or  broth,  and  suet  puddings  containing  currants ;  but  there 
were  no  potatoes  nor  fresh  vegetables.  It  is  clear  therefore,  that,  in  order  to 
obtain  the  proper  variety  of  materials  required  in  nutrition,  we  must  resort 
to  several  of  the  natural  groups — those  particularly  which  comprise  the  succu- 
lent vegetables  and  fruits. 

What  is  the  precise  nature  of  the  materials  furnished  by  these  latter,  yet 
remains  to  be  determined.  Acid  fruits,  such  as  oranges,  lemons,  limes,  etc., 
stand  pre-eminent  as  antiscorbutics,  and  this  fact  led  to  the  conclusion  that 
their  utility  depended  upon  the  vegetable  acids  which  they  contained,  and  the 
use  of  the  latter  in  scurvy  has  been  followed  with  a  certain  degree  of  success. 
Experience  has  shown,  however,  that  the  fresh  juices  and  pulp  of  these  arti- 
cles, particularly  when  green,  are  more  decidedly  antiscorbutic  than  the  same 
materials  when  prepared  by  the  various  methods  of  drying,  cooking,  and 
preserving,  or  than  their  vegetable  acids.  The  influence  of  these  agents  in 
warding  off  or  curing  scurvy,  may  be  of  a  catalytic  nature,  fitting  by  their 
presence  the  organic  matter  otherwise  injurious  or  defective,  for  nutrition,  in 
the  same  manner  for  instance  as  sodium  chloride,  which  does  not  participate 
essentially  by  its  elements  in  the  formation  of  the  solids  and  semi-solids  of 
the  body,  yet  is  indispensable  in  the  fixation  of  new  proximate  principles  in 
those  tissues. 

Dr.  Aldridge2  held  that  the  cause  of  scurvy  was  a  deficiency  in  the  supply 
of  mineral  matter,  phosphorus,  sulphur,  lime,  potassa,  and  soda ;  the  daily 

1  Monthly  Journal  of  Medical  Science,  Aug.  1847.  s  Value  of  Food,  Dublin,  1847. 

VOL.  I. — 19 


290  SCURVY. 

waste  of  sulphur  is  calculated  to  be  about  20  grains,  and  that  of  potassa  and 
soda  80  grains  in  an  adult  of  150  lbs.  (10  stone)  weight.  The  quantity  of 
cereals  that  would  supply  the  waste  of  other  elements  of  the  body  during  a 
single  day,  can  supply  only  17  grains  of  sulphur  and  43  grains  of  the  alkalies; 
and  a  similar  amount  of  leguminous  material  would  give  only  11  grains  of 
sulphur  and  55  of  the  alkalies.  Succulent  vegetables,  on  the  other  hand, 
while  deficient  in  nitrogen  and  the  other  elements,  contain  mineral  matter  in 
abundance.  The  potato  contains  both  organic  and  inorganic  principles  in 
just  proportion  to  compensate  for  the  necessary  waste.  Dr.  Garrod,1  of  Edin- 
burgh, upon  the  strength  of  one  inconclusive  blood  analysis,  declared  that 
scurvy  was  caused  by  the  use  of  food  deficient  in  the  potassium  salts,  the  essen- 
tial change  in  the  blood  in  that  disease  being  brought  about  by  the  insufficient 
supply  of  these  salts.  Neither  of  these  views,  though  ingenious  and  plausible, 
has  received  the  confirmation  of  scientific  research. 

Some  of  the  old  writers,  Sennertus,2  Charleton,3  and  Hoffmann,4  from  observ- 
ing the  wide-spread  character  of  the  disease,  its  destructive  effects  and  exten- 
sion in  communities  and  aggregations  of  individuals,  and  its  seizure  of  nursing 
infants,  adopted  the  idea  that  it  was  contagious,  or  of  a  miasmatic  character, 
depending  upon  a  specific  poison,  just  as  syphilis,  smallpox,  or  malarial 
diseases.  M.  Villemin,5  in  August,  1874,  presented  to  the  Academy  of  Medi- 
cine at  Paris,  a  memoir  in  which  he  endeavored  to  sustain  the  theory  that 
scurvy  was  "une  maladie  endemo-epidemique,  contagieuse,  analogue  au 
typhus,  a  la  peste,  et  resultant  d'un  miasme  particulier."  Rottwil6  has  also 
expressed  similar  views. 


Morbid  Anatomy  of  Scurvy. 

After  death,  the  body  of  a  patient  dead  of  scurvy  presents  slight  evidence 
of  rigor  mortis,  and  is  generally  emaciated,  especially  when  little  food  has 
been  attainable,  or  when  from  the  condition  of  the  gums  and  teeth  it  could 
not  be  masticated  and  swallowed.  Under  reverse  circumstances  the  body 
may  retain  its  rotundity  and  fulness.  It  is  prone  to  rapid  decomposition, 
and  the  skin  is  of  a  dirty-yellowish  or  clay  color,  dry  and  parchment-like, 
more  or  less  scaly  and  rough,  and  marked  by  bluish  or  livid  spots  of  the  most 
varying  size  and  figure.  The  small  and  round  spots  located  at  the  roots  of 
the  hair,  from  one  to  two  lines  in  diameter,  are  caused  by  blood  extravasated 
from  the  vascular  network  around  the  hair  follicles,  beneath  the  cuticle.  The 
larger  and  more  irregular  discolorations  are  located  in  the  deeper  layers  of 
the  cutis.  The  subcutaneous  connective  tissue  is  more  or  less  ocdematous  and 
infiltrated  with  blood,  or  fibrinous  material  tinged  with  blood.  The  bloody 
extravasations  form  swellings  of  a  doughy  feel,  without  well-defined  limita- 
tions, unless  circumscribed  by  resisting  fasciae ;  the  fibrinous  effusions,  on  the 
other  hand,  present  themselves  as  layers  from  one  to  two  lines  in  thickness,  at 
first  gelatinous  and  of  a  pale  yellow  color,  but  subsequently  assuming  a  higher 
organization,  becoming  vascular,  of  a  bright  yellowish-red  color,  firm  and 
even  elastic  to  the  led,  and  with  clearly  defined  outlines.  The  material  be- 
comes so  intimately  Mended  with  the  connective  tissue  as  to  destroy  all 
appearance  of  its  fibrillary  structure.  These  appearances  also  occur  in  the 
connective  t  issue  of  the  muscles,  and  beneath  the  fascia?  forming  their  sheaths, 
lacerating  their  fibres  or  softening  them  to  such  a  degree  that  they  easily 

1  Monthly  Journal  of  Med.  Science,  1848.  2  Med.  pract.,  lit),  iii.  pars  v.  sec.  ii.  cap.  Hi. 

*  De  scorbato,  L672.  *  Medicina  rationalis  systematica,  1739. 

6  Archives  Gun.  de  Medecine,  t.  ii.  1874.  6  Nassauischen  Jahrbucher,  Bd.  xvi.  s.  740. 


MORBID   ANATOMY   OF   SCURVY.  291 

break  down  between  the  fingers.  These  deposits  most  commonly  show  them- 
selves about  the  muscles  of  the  hams,  but  are  occasionally  found  in  the  recti 
and  pectoral  muscles  of  the  trunk,  or  about  the  elbows,  and  beneath  the 
pterygoid  muscles  of  the  face.  In  the  severest  forms  of  the  disease,  effusions 
occur  beneath  the  periosteum,  forming  nodes  of  more  or  less  firmness,  which 
may  lead  to  necrosis  of  the  bone. 

The  joints  are  the  seat  of  serous,  and  occasionally  of  sanguineous,  effusions; 
the  synovial  membranes  have  been  found  eroded,  the  articular  cartilages  soft- 
ened and  separated  from  their  subjacent  connections,  and  even,  in  extreme  cases, 
the  bone  itself  may  be  softened  and  infiltrated  with  blood.  The  joints  may 
also  be  secondarily  involved  by  changes  going  on  in  the  surrounding  con- 
nective tissue.  Morbid  changes  frequently  occur  in  the  serous  membranes^ 
The  pericardium  usually  contains  a  little  clear  serosity ;  not  infrequently  its 
surface  is  softened,  and  its  tissue  easily  lacerable,  or,  as  in  some  cases,  inflamed 
and  the  seat  of  considerable  hemorrhagic  effusion.  The  pleural  cavities  often 
contain  serous  fluid,  and  are  sometimes  the  seat  of  copious  bloody  effusions  ; 
their  walls  are  tinged  with  ecchymotic  discoloration,  and  show  indications  of 
inflammatory  action. 

The  most  constant,  indeed  ever-present,  changes,  are  found  in  the  mouth, 
and  constitute  what  is  known  as  scorbutic  stomatitis.  The  gums  are  livid  and 
swollen,  and  separated  from  the  teeth,  which  they  wholly  or  partially  conceal 
in  their  fungoid  exuberance;  they  display  an  advanced  stage  of  fatty  degene- 
ration, the  tissue  under  the  microscope  presenting  an  abundant  epithelial 
proliferation,  and  an  enormous  production  of  fatty  globules.  The  teeth  them- 
selves are  either  loosened,  or  have  already  fallen  out.  The  nasal,  pharyngeal, 
laryngeal  and  bronchial  mucous  membranes  are  generally  pale,  and  marked 
with  flecks  of  dark  red  color,  and  there  is  present  more  or  less  bloody,  turbid 
fluid.     (Edema  of  the  glottis  is  occasionally  met  with. 

The  nervous  system  is  perhaps  least  frequently  affected,  yet,  occasionally,  the 
ventricles  of  the  brain,  when  opened,  reveal  the  presence  of  serous  or  sanguino- 
serous  fluid,  and  similar  fluids  are  more  often  found  in  the  arachnoid.  The 
brain  itself  is  usually  pale  in  color,  and  its  vessels  collapsed  and  empty.  On 
the  other  hand,  some  cases  display  a  different  state  of  things ;  the  brain  is 
engorged  with  blood,  and  is  the  seat  of  extravasation,  and  in  rare  cases  of 
softening. 

The  heart  is  found  relaxed  and  flabby ;  its  tissue  lacerable  and  atrophied ; 
its  cavities  quite  empty  in  some  cases,  and  in  others  filled  with  dark  fluid 
blood.  The  semilunar  valves  lose  their  elasticity  and  fail  to  close  the  orifices 
accurately,  so  that  water  injected  by  the  aorta  runs  freeh*  into  the  left  ventri- 
cle. The  cardiac  walls  present  a  yellowish  tint  on  section,  and  are  often  the 
seat  of  effusions.  In  cases  in  which  the  disease  has  been  of  short  duration, 
the  blood  is  of  a  dark  color,  sometimes  fluid  or  loosely  coagulated,  while  at 
other  times  it  is  very  firmly  clotted;  in  prolonged  cases,  on  the  other  hand, 
the  blood  is  usually  of  a  lighter  color,  and  more  uniformly  fluid,  yet  firm 
coagula  are  by  no  means  uncommon  in  these  cases,  as  noticed  by  Rouppe, 
Audral,1  Fauvel,  and  others.  The  older  coagula  are  thick,  elastic,  and  closely 
adherent  to  the  inner  surface  of  the  heart,  but  gradually  merge  into  more 
recent,  looser,  and  reddish  depositions.  The  tissue  of  the  heart  becomes 
altered,  the  muscular  fibres  undergoing  granular  and  fatty  degeneration,  so 
that  at  points  the  sarcous  elements  are  entirely  replaced  by  the  new  material. 
The  endocardium  and  the  inner  surface  of  the  great  vessels  show  the  evidences 
of  sanguineous  imbibition.  The  arterial  and 'capillary  walls  exhibit  no  signs 
of  marked  change ;  Lasegue  and  Le  G-roux  examined  the  capillaries  in  several 

1  Archives  Geuerales  de  Medecine,  1847. 


292  scurvy. 

cases  of  scurvy  which  proved  fatal  in  the  siege  of  Paris  in  1871,  and  found 
nothing,  with  the  exception  of  scattered  fatty  granulations  in  their  walls.1 
Analogous  changes  to  those  found  in  the  cardiac  muscles,  also  occur  in  the 
muscular  structures  of  other  localities.  According  to  Leven,2  the  first  muscles 
to  undergo  fatty  degeneration  are  those  of  the  loins ;  in  one  of  his  cases,  the 
fibres  of  the  sacro-lumbar  muscles  had  completely  lost  their  striation,  and  the 
sarcolemma  had  in  great  part  disappeared  ;  there  remained  widely  separated, 
longitudinal  lines,  with  the  intervals  crowded  with  granular  and  fatty  matter. 
The  muscles  of  the  calf  of  the  leg  showed  the  same  advanced  changes,  while 
those  of  the  thigh  were  less  altered. 

The  lungs  present  as  varying  changes  as  those  in  the  heart,  They  may  be 
collapsed  and  bloodless,  but  as  a  rule  are  infiltrated  with  bloody  serosity, 
particularly  in  those  cases  which  during  life  showed  large  amounts  of  albumen 
in  the  urine ;  ecchymoses  on  the  surface  of  the  lungs  are  not  uncommon,  and 
they  are  usually  quite  superficial.  The  posterior  portions  of  these  organs 
often  show  indications  of  hypostatic  congestion  or  hepatization,  and  occasion- 
ally of  gangrene.  In  the  latter  case,  the  gangrenous  tissue  breaks  down  easily 
under  the  linger  into  a  pulp  which  emits  an  offensive  odor.  A  fibrinous  and 
bloody  exudation  is  also  found  in  various  parts  of  the  lungs,  chiefly  interiorly 
and  posteriorly.  The  bronchial  mucous  membrane  is  more  or  less  maculated, 
and  contains  a  bloody  mucosity ;  and  the  same  is  true  of  the  trachea,  and 
larynx. 

The  digestive  system  is  seldom  or  never  free  from  post-mortem  changes. 
The  mucous  membrane  of  the  stomach  and  small  intestine  is  often  softened  and 
thickened  ;  in  places  ulcerated,  even  to  the  depth  of  the  muscular  layers,  the 
edges  of  the  ulcers  being  everted  and  infiltrated  with  blood ;  and  Dr.  Ritchie 
finds  the  solitary  glands  in  the  lower  part  of  the  ileum  enlarged.  Similar 
lesions  are  found  in  the  large  intestines,  and  in  some  places,  beneath  a  dark- 
red,  pulpy  material,  easily  removable  by  wiping,  the  subjacent  tissues  are 
found  softened,  infiltrated,  or  even  destroyed.  In  other  cases  extensive  folli- 
cular ulceration  is  seen,  of  a  rounded  shape,  and  with  infiltrated  borders. 
The  entire  length  of  the  gastro-intestinal  mucous  membrane  is  more  or  less 
stippled  with  sanguineous  effusions,  varying  from  a  pink  to  a  blackish-green 
tinge,  and  blood  in  greater  or  less  quantity  is  poured  out  into  the  canal. 

The  liver  always  presents  more  or  less  evidence  of  fatty  degeneration ;  it  is 
sometimes  enlarged,  gorged  with  dark  blood,  and  softened,  with  its  surface 
marked  with  spots  of  hemorrhagic  infiltrations.  The  spleen  is  occasionally 
found  of  greater  magnitude  than  natural,  filled  with  grumous  blood,  its 
surface  discolored,  and  its  structure  lacerable.  Or  it  may  be  the  seat  of 
wedge-shaped  infarctions.  Vernette  found  the  spleen  enlarged  in  only  8  out 
of  500  cases  of  scurvy.  The  pancreas  presents  also  occasional  evidence  of 
hemorrhagic  effusion  and  softening. 

The  kidneys,  although  there  may  have  been  albumen  in  the  urine  during 
life,  are  usually  found  unaltered.  Dr.  Ilimmelstiern  has  observed,  in  a  few 
cases,  a  yellowish-red  layer  upon  the  mucous  membrane  of  the  pelves  and 
ureters,and  Heyfelder  reports  Laving  found  the  kidneys  engorged  with  blood, 
and  the  lining'  membrane  of  the  pelves,  ureters,  and  bladder,  here  and  there 
covered  with  bloody  mums.  In  those  eases  in  which  the  urine  during  life 
had  contained  large  quantities  of  albumen,  and  which  had  been  complicated 
with  dropsy,  the  kidneys  presented  the  ordinary  parenchymatous  degenera- 
tions found'  in  Bright's  disease.  Opitz,  in  prolonged  eases  of  scurvy ,_  has  seen 
atrophy  of  the  kidneys.  The  renal  capsule  is  ecchymosed  at  points,  and 
Cajka  has  reported  in  some  cases  the  presence  of  small  infarctions  in  the  cor- 

1  Archives  Gen.  de  MSdecine,  Dec.  1871.  2  Leven,  Une  epidemic  de  Seorbut,  1862. 


PATHOLOGY    OF    SCURVY.  293 

tical  substance,  and  less  often  in  the  deeper  structures.  The  pelvic,  ureteric, 
and  vesical  mucous  membranes  present  not  infrequently  spots  of  hemorrhagic 
discoloration,  as  well  as  of  softening  and  erosion,  and  the  contained  urine  is 
tinged  with  blood. 


Pathology  of  Scurvy. 

Hoffman,  Boerhave,  Huxham,  Lind,  and  many  others  of  the  older  obser- 
vers, recorded  their  opinion  that  in  the  blood  were  to  be  sought  the  essential 
changes  upon  which  the  scorbutic  phenomena  depended,  and  they  generally 
considered  the  nature  of  these  changes  to  consist  in  a  breaking  down  of  the 
blood-corpuscles,  or  a  dissolved  condition  of  the  blood,  which  in  turn  led  to 
the  sanguineous  effusions  so  common  in  scurvy ;  a  theory  that  had  currency 
for  many  years,  until  chemical  research  finally  dissipated  the  unfounded 
assertions  on  which  it  was  based,  and  led  to  the  establishment  of  more  correct 
views.  We  still,  however,  have  to  deplore  the  fact  that  though  much  error 
has  thus  been  removed,  yet  few  new  truths  have  been  established  by  these 
investigations.  The  analyses  are,  as  yet,  too  discrepant  and  too  few  in  num- 
ber to  determine  with  precision  the  exact  nature  of  the  chemical  alterations 
in  the  blood.  The  disease  has  happily  become  so  infrequent  that  few  oppor- 
tunities now  present  themselves  for  chemical  examination,  and  rarely  can 
the  quantity  of  blood  necessary  for  the  purpose  be  obtained,  with  safety,  by 
venesection,  in  this  class  of  patients.  The  want  of  uniformity,  and  the  diffi- 
culties inherent  to  the  process,  as  well  as  the  varying  conditions  under  which 
the  analyses  have  been  made,  have  contributed  in  no  small  degree  to  the  dis- 
crepant results  which  have  hitherto  been  obtained. 

The  frequent  effusions  of  blood  in  scurvy  led  Andral  to  suspect  that  the 
chief  factor  in  scorbutic  blood  was  the  decrease  of  fibrin^  which  was  in  per- 
fect accord  with  a  theory  that  he  had  formed  that  this  change  was  the 
uniform  cause  of  passive  hemorrhage. 

Magendie  had  already  given  experimental  support  to  this  conjecture,  by 
inducing  in  animals  phenomena  analogous  to  those  of  scurvy,  by  the  injection 
into  the  veins  of  defibrinated  blood,  or  alkaline  solutions.  Andral1  believed 
his  views  confirmed  when  in  1841  he  analyzed  on  two  occasions  the  blood  of 
scorbutic  patients,  and  found  the  fibrin  reduced  to  1.6  parts  per  thousand. 
Similar  results  were  obtained  by  Eckstein  and  Fremy.  On  the  other  hand, 
the  blood  was  analyzed  by  Mr.  Busk,  about  the  same  time,  in  three  well- 
marked  cases  of  scurvy  that  occurred  on  the  "Dreadnought"  Hospital-ship,  and 
in  all  of  them  the  fibrin  was  in  excess  of  the  normal  amount,  the  least  being 
4.5,  and  the  greatest  6.5  parts  per  thousand.  In  perfect  accord  with  Busk's 
results,  were  the  analyses  of  the  blood  of  five  scorbutic  females,  communicated 
in  a  note  to  the  Academy  of  Sciences,  in  1847,  by  Becquerel  and  Rodier.  In 
no  ease  was  the  fibrin  diminished,  but  in  some  it  was  sensibly  increased.  In 
a  subsequent  case,  Andral  found  that  the  fibrin,  instead  of  being  less,  exceeded 
the  physiological  mean,  reaching  4.4  parts,  and  he  concluded  that  a  diminu- 
tion of  this  element  was  not  a  necessary  and  constant  occurrence,  but  only  an 
effect,  a  result  of  prior  morbid  modifications,  and  a  consequence  which  was 
produced  more  or  less  frequently  according  to  the  severity  and  duration  of 
the  disease.  Parmentier  and  Deyeux  found  the  blood  of  three  scorbutics  to 
resemble  inflammatory  blood,  in  respect  to  fibrin,  while  Frick  obtained  in 
one  analysis  7.6  parts  of  fibrin,  and  Leven  4.3  parts. 

In  mild  cases  of  scurvy,  neither  the  color,  the  alkalinity,  nor  the  coagula- 


Essai  d'hematologie  pathologique. 


294  scurvy. 

bility  of  the  blood  differs  from  that  of  blood  in  health,  though  "Wood  alleges 
that  the  clot  is  loose  and  cotton-like,  and  Canstatt  that  its  coagulability,  in 
consequence  of  the  large  proportion  of  saline  matters,  is  diminished.  In 
Busk's  cases,  the  separation  of  the  clot  and  serum  was  as  perfect,  and  took 
place  as  rapidly,  as  in  healthy  blood,  and  in  two  of  them  the  blood  was  both 
buffed  and  cupped,  as  it  was  also  in  Leven's  cases.  In  two  of  the  most  severe 
of  Becquerel's  cases  the  blood  coagulated  firmly,  and  in  a  slight  case  the  clot 
was  dark  and  loose.  The  albumen  of  the  blood  shows  no  marked  change  as 
regards  its  quantity.  The  five  analyses  of  Becquerel  and  Rodier  showed  the 
average  amount  of  organic  matters  of  the  serum  to  be  64.3  parts  in  a  thousand, 
the  smallest  being  56.2  and  the  largest  69.2  parts.  One  thousand  parts  of  the 
serum  of  the  same  cases  gave  an  average  of  72.1  parts  of  organic  matter. 
Trick's  single  case  gave  87.045  parts  per  thousand,  and  the  average  of  Busk's 
was  78.2  parts,  while  Chotin  and  Bouvier  obtained  only  62.3  parts.  The 
last-mentioned  writers  have  recorded  a  fact  in  connection  with  the  physical 
characters  of  scorbutic  blood  that  deserves  notice:  the  blood  in  one  case  did 
not  coagulate  at  the  usual  temperature— about  158°  F. — but  required  a  tem- 
perature some  degrees  higher  for  that  purpose.  The  red  corpuscles  in  all  the 
foregoing  cases  were  notably  diminished,  the  largest  amount  given  being 
117.078  parts  per  thousand,  while  the  lowest  was  47.8  parts.  In  Andral's 
second  case  the  globules  had  decreased  to  44.4  parts  per  thousand,  the  lowest 
amount  yet  recorded. 

The  alkalinity  of  the  blood  seems  not  to  be  changed,  although  Chotin  and 
Bouvier  notice  a  slight  increase.  The  saline  constituents  do  not  vary  greatly 
from  the  normal  standard.  The  average  amount  in  Becquerel  and  Rodier's, 
and  Busk's,  cases  was  8.1  parts  per  thousand,  the  smallest  being  5.5  parts  and 
the  largest  11.5.  In  Dr.  Ritchie's  two  analyses,  the  proportion  of  saline 
matters  is  given  as  6.44  and  6.82  parts  per  thousand.  Opitz  and  Schneider 
have  found  less  than  the  physiological  mean.  In  Frick's  case  the  amount 
was  8.8,  the  iron  being  0.721  parts  per  thousand,  and  0.782  to  127  parts  of 
globules ;  lime  0.110,  chlorides  6.846,  and  phosphates  1.116  parts  per  thou- 
sand. The  iron  was  in  excess  of  that  in  the  normal  blood,  but  in  Becquerel's 
cases  the  mean  was  0.381 — less  than  the  normal.  The  proportion  of  iron  in 
Duchek's  cases  was  respectively  0.393,  0.402,  and  0.476  parts,  giving  a  mean 
of  0.423  parts  per  thousand,  which  nearly  approximates  the  normal.  Garrod 
in  one  analysis  of  the  blood  found  a  deficiency  of  the  potassium  salts,  upon 
which  he  erected  his  well-known  theory  of  the  etiology  of  the  disease.  It  is 
an  interesting  fact  that  in  the  physiological  state  the  quantity  of  sodium 
chloride  is  not  subject  to  variation,  any  excess  introduced  with  the  food  being 
thrown  off  by  the  kidneys.  The  quantity  in  the  urine  bears  a  relation  to  the 
amount  introduced  as  food,  but  the  proportion  in  the  blood  is  constant. 

The  quantity  of  water  in  the  blood  has  been  found  to  be  increased  in  all 
the  analyses  which  have  been  made.  Chotin  and  Bouvier  estimated  water 
and  loss  at  831.1 ;  in  Frick's  case  it  was  791.69  parts  per  thousand  ;  and  in 
Becquerel's  five  cases  it  was  put  at  807.7,  810.9,  811,  813.7,  and  854.0  parts 
per  thousand  respectively.  In  Busk's  three  cases  the  lowest  amount  Avas 
835.9,  and  the  highest  S49.9  parts  per  thousand.  The  specific  gravity  of  the 
defibrinated  blood  was  in  all  cases  low  in  comparison  with  the  normal  stan- 
dard, 1057,  the  average  in  Becquerel  and  Rodier's  cases  being  1047.2,  the 
lowesl  1038.8,  and  the  highest  1051.7.  In  the  single  observation  of  Chotin 
ainl  Bouvier  it  Avas  1060.  The  specific  gravity  of  the  serum  was  also  less 
than  normal  d  027),  the  average  of  lour  of  Becquerel's  analyst's  giving  1023.8, 
the  lowesl  102H. s  and  the  highest  1025.5.  Busk  gives  1025  in  one  case  and 
1028  in  another. 

The  results  of  the  most  recent  analyses,  those  of  Chalvet,  are  shown  in  the 


SYMPTOMS   OF   SCURVY.  295 

following  table,  in  which  scorbutic  blood  is  contrasted  with  that  of  a  healthy 
robust  female : — 

Scorbutic  Blood.      Healthy  Blood. 

Water 848.492  779.225 

Solid  matters 151.508  220.775 

Dry  clot 140.194  209.000 

Albumen 72.304  68.717 

Fibrin 4.342  2.162 

Globules 63.548  138.121 

Extractive  matter — by  absolute  alcohol        .  10.312  8.013 

by  ether        .         .         .  1.002  1.300 

Ashes  of  clot 3.000  5.691 

Peroxide  of  iron  of  globules         .                   .  1.060  2.259 

Potassium  of  globules           .  0.329  0.625 

From  the  conflicting  statements  of  the  various  observers,  the  following 
conclusions  may  be  formed :  That  in  scorbutic  blood,  water  is  in  excess ;  that 
there  is  on  the  one  hand  a  marked  increase  of  the  fibrin,  and  in  a  less  degree 
of  the  albumen  and  extractive  matters,  while  on  the  other  hand  there  is  a 
marked  decrease  of  the  globules,  and  in  a  less  degree  of  the  mineral  matters. 
On  the  authority  of  Chalvet,  it  may  also  be  stated  that  demineralization  of 
the  muscular  tissue  is  a  notable  chemical  feature  in  scurvy. 

So  far,  microscopic  examination  has  been  entirely  negative.  Hay  em1 
found  no  appreciable  alteration  from  healthy  blood,  and  in  this  view  Leven2 
concurs ;  while  Laboulbene3  notes  the  occurrence  of  an  unusual  number  of 
white  globules. 

Symptoms  of  Scurvy. 

The  symptoms  of  scurvy  are  insidiously,  and  usually  slowly,  developed 
under  the  influence  of  the  efficient  causes,  and  it  runs  a  chronic  course,  often 
extending  over  six  or  seven  months,  especially  in  cases  in  which  the  hygienic 
surroundings  of  the  patient  have  been  imperfectly  or  not  at  all  rectified.  In 
lighter  cases  this  course  is  much  shorter.  A  gradual  alteration  of  the  nutri- 
tive processes  first  occurs,  until  what  might  be  called  a  scorbutic  cachexia  is 
established,  in  a  period  varying  from  a  few  weeks  to  several  months.  The 
initial  symptoms  consist  in  the  skin  losing  its  color  and  tone,  and  assuming  a 
yellowish  or  earthy  hue;  it  is  relaxed,  dry,  unperspiring,  and  rough;  in  the 
legs,  particularly,  this  roughness  is  very  marked,  and  the  skin,  when  rubbed, 
sheds  an  abundance  of  furfuraceous  scales.  The  cutaneous  follicles,  markedly 
on  the  extensor  aspect  of  the  lower  extremity,  are  prominent,  similar  in  ap- 
pearance and  feel  to  the  condition  known  as  "goose  flesh."  Kouppe4  calls 
this  the  signum  primum  pathognomonicum.  Dark-red  or  brownish  flecks,  of 
a  circular  outline,  and  of  varying  but  small  size,  not  unlike  flea-bites,  appear 
on  the  face  and  limbs.  The  cutaneous  circulation  is  feeble,  and  the  superfi- 
cial warmth  less  than  natural;  slight  depression  of  the  atmospheric  tempera- 
ture produces  a  sensation  of  chilliness,  and  the  feet  and  hands  are  cold.  On 
assuming  the  erect  posture,  the  patient  complains  of  headache  and  dizziness. 
The  muscles  are  relaxed,  and  soft  to  the  feel,  and  a  corresponding  loss  of  vigor 
and  strength  is  experienced  by  the  patient,  who  is  indisposed  to  exert  himself 
in  the  performance  of  his  customary  duties,  and  seeks  repose  and  freedom 
from  feelings  of  fatigue  and  languor  in  recumbency.  This  prostration  is 
occasionally  so  extreme  that  the  slightest  efforts  in  attempting  to  stand  or 
walk  are  attended  with  rapid   action  of  the  heart,  accelerated  respiratory 

1  Mem.  de  la  Societe  de  Biologie.  «  Epidemie  de  Scorbut. 

8  Communication  to  the  Academie  des  Sciences,  1871.  4  De  morbis  navigantium. 


296  scurvy. 

movements,  and  a  sense  of  suffocation  or  breathlessness.  The  general  circula- 
tion is  impaired;  the  heart  acts  feebly;  the  arteries  are  contracted  ;  and  the 
pulse  is  slow,  small,  and  compressible. 

The  mental  powers  are  equally  impaired.  The  face  wears  a  haggard  and 
depressed  expression;  gloomy  forebodings  of  the  future,  and  disinclination  to 
turn  the  attention  to  the  usual  mental  pursuits,  are  markedly  present — a  dis- 
inclination that  subsequently  merges  into  complete  apathy  or  indifference  to 
passing  events,  or  even  into  somnolency. 

Pains  in  the  legs,  joints,  and  loins,  are  early  manifestations;  they  closely 
resemble  those  of  rheumatism,  for  which  they  are  often  mistaken.  The  pains 
are  not  exacerbated  at  night,  but,  on  the  contrary,  are  often  more  severe  by 
day.  Not  unfrequently,  lancinating  pains  in  the  muscles  of  the  chest  are 
complained  of.  The  sleep  is  not  disturbed  until  the  disease  has  made  some 
advance,  when  it  becomes  broken,  and  no  longer  refreshing.  The  appetite  is 
usually  unimpaired  in  the  early  periods  of  the  disease,  and  even  throughout 
its  course,  the  condition  of  the  mouth  alone  preventing  the  patient  from  in- 
dulging his  desire  for  food,  even,  as  is  occasionally  noticed,  to  voracity. 
There  may  be  a  yearning  for  certain  articles  of  diet,  principally  those  of  an 
acid  character;  but,  on  the  other  hand,  some  cases  present  exactly  the  reverse 
condition — a  disgust  for  food  in  general,  or  for  particular  varieties ;  or  the 
appetite  may  be  vacillating,  at  one  time  craving,  and  at  another  repelling 
nourishment.  There  is  no  noticeable  change  in  the  normal  thirst,*  unless  on 
the  occurrence  of  febrile  complications,  when  it  is  increased.  The  gums  do 
not,  at  this  stage  of  the  disease,  present  the  livid,  swollen  appearance  of  fully- 
developed  scurvy,  but,  on  the  contrary,  are  generally  paler  than  usual,  with 
a  slightly  tumid  or  everted  line  on  their  free  margins,  and  are  slightly  tender 
on  pressure.  The  breath  is  commonly  offensive,  and  the  patient  complains 
of  a  bad  taste  in  the  mouth.  The  tongue  is  flabby  and  large,  though  clean 
and  pale,  and  the  bowels  are  inclined  to  be  sluggish. 

This  preliminary  state  is  followed,  after  varying  intervals  of  time,  by  cer- 
tain local  phenomena  which  are  quite  characteristic  of  the  disease.  There  is 
a  marked  tendency  to  extravasation  of  blood  into  the  tissues,  either  sponta- 
neously or  upon  the  infliction  of  slight  injuries  or  wounds.  Fibrinous  exuda- 
tions occur  sooner  or  later  into  the  gums,  which  become  darkened  in  color, 
inflamed,  swollen,  spongy,  and  which  bleed  upon  the  slightest  touch,  finally 
separating  from  the  teeth.  These  results  are  due  in  part  to  the  considerable 
amount  of  pressure  to  which  these  parts  are  subject  in  mastication,  and  it  is  a 
conspicuous  fact  that  the  gums  of  edentulous  jaws  remain  free  from  these 
changes.  In  a  few  cases  the  gums  are  but  slightly  altered,  perhaps  oedema- 
tons  only,  or  jutting  upon  pressure ;  or  they  become  the  site  of  bloody  extra- 
vasations. In  severer  examples,  in  later  stages  of  the  disease,  these  various 
alterations  progress  to  an  extreme  degree,  and  the  extravasation  is  so  volumi- 
nous that  the  gums  present  great,  fungous,  lacerable  excrescences,  which  may 
finally  break  down  into  a  suppurating,  brownish,  and  very  fetid  mass,  which 
communicates  to  the  breath  an  odor  of  a  most  offensive  character.  The  rest 
of  the  mucous  membrane  of  the  mouth  remains  unaltered,  or  at  most  slightly 
ecehymotic.  Samson  and  Charpentier,1  in  a  large  number  of  cases  saw  this 
but  once,  and  in  one  of  Leven's2  cases  the  fungous  growth  invaded  the  palatal 
mucous  membrane,  extending  to  the  anterior  pillars  of  the  fauces.  The  sali- 
vary glands  are  enlarged  and  swollen;  the  tongue  is  imprinted  with  the  form 
of  I  lie  teeth,  while  (he  latter  become  encrusted  with  tartar,  and  more  or  less 
concealed  by  the  exuberant  gums,  or,  becoming  gradually  loosened  from  the 
alveoli,  finally  drop  out.     The  morbid  process  may  even  extend  to  the  bone 

1  Eturle  sur  le  Scorbut,  1871.  2  Une  6pid£mie  de  Scorbut,  p.  28,  1872. 


SYMPTOMS   OF   SCURVY.  297 

itself,  and  necrosis  and  extensive  exfoliation  may  follow.  Mastication  is 
more  or  less  painful,  and  often  impossible,  so  that  the  patient  is  reduced  to 
the  necessity  of  prolonging  life  by  the  use  of  fluid  or  semi-solid  food.  Under 
the  influence  of  appropriate  treatment,  it  is  remarkable  how  rapidly  (in  from 
two  to  four  weeks)  these  marked  changes  recede,  and  the  parts  resume  their 
normal  condition;  yet  it  occasionally  occurs  that  permanent,  callous  thicken- 
ing of  the  gums  results. 

In  the  progress  of  the  disease,  effusions  of  blood  under  the  skin  are  of  early 
occurrence.  They  are  at  first  located  in  the  superficial  stratum  of  the  cutis, 
or  just  beneath  the  epidermis,  especially  around  the  roots  of  the  hair;  and 
present  themselves  as  roundish,  bluish-red  fleeks,  varying  in  size  from  that  of 
a  pin's-head  to  that  of  a  split  pea,  not  effaceable  by  pressure  with  the  tip  of 
the  finger,  but  slightly,  if  at  all,  elevated  above  the  surface,  and  enduring  for 
weeks  together.  The  nutrition  of  the  hair-follicles  is  impaired,  so  that  the 
hairs  are  often  either  lost,  broken,  or  distorted.  These  petechias  fade  in  color 
with  progressive  improvement  in  the  case,  and  finally  disappear,  leaving 
behind  brownish-yellow  discolorations.  They  first  appear  in  the  extremities, 
particularly  the  lower  limbs,  then  in  the  face,  and  lastly  in  the  trunk.  At  a 
later  period,  extravasations  of  a  larger  size  and  more  irregular  form  occur  in 
the  deeper  layers  of  the  derma.  They  vary  in  size  from  that  of  a  finger-nail 
to  blotches  two  or  three  inches  in  diameter;  at  first  reddish  in  color,  and 
subsequently  of  a  bluish-red.  When  recession  occurs,  under  appropriate 
treatment,  the  color  passes  through  various  shades  of  violet,  blue,  green,  and 
yellow,  as  in  ordinary  traumatic  ecchymoses.  Outpourings  of  blood  also 
occur  into  the  subcutaneous  connective  tissue,  notably  that  of  the  legs, 
and  in  localities  where  connective  tissue  is  particularly  abundant  and  loose, 
as  in  the  ham  and  axilla.  The  dispersion  of  blood  in  this  tissue  may  be  so 
considerable  as  to  cause  the  legs  from  the  knees  down  to  present  a  uniform, 
dark-blue  coloration,  that  in  form  may  not  inaptly  be  compared  to  a  stocking. 
The  upper  extremities  also  suffer,  usually  on  their  inner  side,  from  the  arm- 
pit down,  the  extravasation  rarely  reaching,  however,  to  the  hand.  These 
extravasations  take  place  also  after  the  infliction  of  very  slight  injuries,  as 
from  blows,  or  the  pressure  of  hard  bodies,  or  even  from  the  mechanical 
effects  of  prolonged  dependency  of  the  limbs,  as  in  riding  on  horseback.  Ex- 
travasations of  a  similar  nature  are  occasionally  present  in  the  connect  ive 
tissues  of  the  muscles  themselves,  or  between  them,  giving  rise  to  swellings 
of  various  forms  and  dimensions.  Nearly  always,  along  with  the  sanguineous 
effusions,  there  is  more  or  less  oedema,  usually  beginning  at  the  ankles,  and 
gradually  extending  upwards ;  in  some  cases,  there  are  puffiness  of  the  face 
and  general  anasarca,  so  that  deep  pits  remain  on  pressure. 

This  profound  impairment  of  nutrition  of  the  skin  continuing,  in  the  worst 
cases  blood  is  effused  beneath  the  cuticle,  forming  blebs  of  varying  size,  which 
finally  break  and  leave  superficial,  ulcerated  surfaces,  which  ultimately  be- 
come covered  with  flabby,  exuberant  granulations,  pouring  out  a  purulent, 
often  offensive  sanies,  and  bleeding  upon  the  slightest  touch.  In  some  cases 
the  ulceration  begins  in  the  petechias  at  the  hair-roots,  and  a  number  of 
these  running  together  form  a  large  ulcer.  The  destruction  of  tissue  by 
ulceration  is  disposed  to  spread  more  widely  and  deeply,  and  is  often  of  a 
most  intractable  character.  Old  cicatrices  are  the  first  tissues  in  these  cases 
to  take  on  the  ulcerative  action.  Certain  muscles,  chiefly  those  of  the  legs, 
and  notably  the  gastrocnemii,  the  abdominal  and  pectoral  muscles,  the  psoas 
magnus,  and  the  pterygoids,  may  become  the  seat  of  fibrinous  extravasations, 
which  finally  change,  by  lapse  of  time,  into  hard,  firm  tumors,  impairing  the 
functions  of  those  parts,  and  leading  to  contractions  of  the  limbs. 

The  symptoms  in  certain  epidemics  of  extraordinary  severity,  have  dis- 


298  scurvy. 

played  alterations  in  still  deeper  structures.  Effusions  occur  between  the 
]n  riosteum  and  the  bone,  forming  painful,  hard,  and  resisting  nodes  of  vary- 
ing dimensions,  especially  along  the  course  of  the  tibiae,  upon  the  scapulae, 
and  upon  the  maxillie.  In  young  persons  the  epiphyses  are  separated  from 
the  shafts  of  the  long  bones,  and  in  other  cases  the  ribs  become  necrosed  and 
disarticulated  from  the  sternum,  producing  a  creaking  noise  during  respira- 
tory movements,  as  related  by  Poupart.1  This  occurs  mostly  on  one  side 
and  about  the  middle  of  the  series,  yet  it  has  been  noted  to  occur  on  both 
sides,  so  that  the  sternum  and  attached  cartilages,  deprived  of  support,  were 
perceptibly  sunken.  Recently  repaired  fractures  have  been  known  to  recur 
under  the  influence  of  scurvy,  from  destruction  of  the  callus.2  The  articula- 
tions as  well  as  the  bones  in  very  severe  cases  of  scurvy  present  evidences  of 
disease,  consisting  in  periarticular  effusions  which  involve  the  surrounding 
soft  parts,  producing  impairment  of  motion,  enlargement,  and  false  anchylosis, 
and  even  destroying  the  normal  anatomical  relation  of  the  osseous  surfaces 
so  as  to  determine  deformities.  These  changes  are  usually  attended  with 
severe  pain,  and  most  commonly  occur  in  the  ankle,  knee,  shoulder  and  hip 
joints,  and  disappear  tardily,  requiring  perhaps  months  for  their  recession,  if 
indeed  this  takes  place  at  all. 

The  symptoms  manifested  by  the  circulatory  organs  are  prominent  from  an 
early  period  of  the  disease.  The  pulsations  of  the  heart  are  slower,  feebler, 
irregular,  and  often  intermittent ;  its  impulse  is  decreased,  or  becomes  quite 
imperceptible  ;  and  when  the  associated  anaemia  has  progressed  to  a  certain 
extent,  a  systolic  murmur  may  be  audible.  The  arterial  and  venous  channels 
are  of  diminished  calibre ;  the  pulse  becomes  soft,  of  less  volume,  and  tardier ; 
and  a  venous  murmur  may  sometimes  be  heard  in  the  cervical  veins.  The 
remarkable  nutritive  changes  in  the  capillary  walls,  in  part  account  for  the 
numerous  hemorrhages  which  occur  both  by  rhexis  and  diapedesis.  The  most 
frequent  is  epistaxis  ;  the  slightest  blows,  sneezing,  or  blowing  the  nose,  will 
often  determine  it,  or  it  may  occur  spontaneously,  and  in  severer  cases  with 
such  profuseness  as  to  threaten  impending  dissolution,  requiring  nothing  less 
than  timeous  introduction  of  the  tampon  to  rescue  the  victim.  Hemorrhage 
from  the  lungs  is  of  rare  occurrence,  and  when  it  does  occur  is  rather  indicative 
of  pre-existing  pulmonary  disease,  such  as  phthisis,  or  of  the  approach  of  a 
complication  such  as  an  infarction  or  gangrene,  than  a  constituent  feature  of 
scurvy.  ILematemesis  is  less  uncommon,  but  is  by  no  means  frequent;  the 
blood  ejected  from  the  stomach  is  usually  limited  in  quantity,  but  in  isolated 
examples  the  bleeding  is  profuse,  producing  great  exhaustion  and  a  sense  of 
cardiac  depression  which  preludes  speedy  death.  Hemorrhage  from  the 
bowels  is  also  an  ill-omened  feature,  completely  blanching  the  patient,  and 
presaging  early  exhaustion  and  death.  Blood  may  also  appear  as  a  product 
of  a  complicating  dysentery  which  determines  abundant,  offensive  discharges 
that  may  run  on  tor  several  weeks  before  the  patient  is  finally  exhausted. 
Hsematuria  sometimes  occurs,  especially  in  broken-down  and  cachectic  sub- 
jects, and  in  an  advanced  stage  of  scurvy.  All  of  these  forms  of  hemorrhagic 
effusion,  now  mentioned  as  localized  in  the  mucous  membranes,  are  to  be 
deprecated  as  exercisinga  pernicious  influence,  seriously  aggravating  ordinary 
cases,  and  fatally  jeopardizing  the  issue  of  severe  ones. 

Effusiveand  inflammatory  complications  are  also  encountered  in  the  serous 
Structures,  and  usually  in  eases  of  great  severity,  though  they  occasionally 
present  themselves  when  the  more  common  localized  phenomena  of  scurvy 
are   not  particularly  prominent.     These  complications  may  be  marked  by  a 

1  Memoires  de  L'Acadernie  dee  Sciences,  p.  237,  1(500  ;  and  Philosophical  Transactions,  vol.  xv. 

2  Anson's  Voyage  around  the  World,  edited  by  Walter. 


SYMPTOMS   OF   SCURVY.  299 

gradual  accession,  or  they  may  rapidly  arise  and  involve  the  patient,  just 
before  in  apparent  security,  in  the  greatest  peril.  These  incursions  are  almost 
always  attended  by  febrile  exacerbations,  and  the  usual  grouping  of  clinical 
characters  denotive  of  the  same  pathological  conditions  arising  under  ordi- 
nary circumstances.  The  local  complications  may  cither  affect  the  pleura  or 
pericardium,  or  both.  In  Dr.  Karawajew's1  sixty  antopsic  examinations, 
pericardial  effusions  were  noticed  in  thirty,  pleural  in  thirty,  pericardial  and 
pleural  in  six,  peritoneal  in  seven,  and  arachnoideal  in  only  one.  The  exu- 
dations are  sero-sanguinolent  or  fibrinous  in  character,  and  sometimes  reach 
the  inordinate  quantity  of  four  or  five  pounds,  occasioning  the  patient  the 
utmost  distress,  and  embarrassing  the  respiratory  and  circulatory  functions. 
Although  these  augment  in  a  high  degree  the  risk  to  life,  yet  under  prompt 
and  appropriate  treatment  recovery  may  take  place,  and  the  effusions  vanish 
with  surprising  rapidity. 

Hemorrhagic  extravasation  into  the  nervous  centres  is  a  very  rare  occurrence. 
It  has  not  been  as  yet  recorded  as  having  occurred  in  the  brain-substance 
itself,  but  has  in  several  instances  been  noted  between  the  meninges,  producing 
headache,  dizziness,  vertigo  and  finally  somnolence,  delirium,  and  coma. 
Opitz'"  relates  an  interesting  case  in  which  convulsions  suddenly  occurred  with 
unconsciousness,  followed  by  hemiplegia  of  the  left  side  of  the  body  and  the 
corresponding  side  of  the  face.  After  twenty -four  hours,  consciousness  returned 
and  the  paralysis  had  disappeared.  There  were  however  headache  and  hyper- 
esthesia of  the  upper  extremities  present;  twelve  days  later  these  also  receded, 
and  the  patient  finally  recovered.  The  same  author  records  paralysis  as 
occurring  in  one  case  from  extravasation  into  the  spinal  meninges.  Dr.  Sam- 
son observed  an  instance  in  which  a  fibrinous  effusion  formed  upon  the  sciatic 
nerve,  with  consequent  pain.  In  the  circulatory  system,  symptoms  always  of 
threatening  and  often  of  fatal  import  arise ;  embolism  may  occur  at  various 
points,  particularly  in  the  lungs  and  spleen,  occasioning  hemorrhagic  infarc-' 
tions  which  have  undoubtedly  been  the  occasion  of  the  sudden  deaths  some- 
times observed  in  scorbutic  cases  not  apparently  of  a  very  dangerous  form, 
nor  attended  with  an  excessive  degree  of  exhaustion. 

The  urinary  system  supplies  no  prominent  symptoms ;  the  statements  as  to 
the  condition  of  the  kidneys  and  the  composition  of  the  urine  are  contradic- 
tory. The  urine  not  unfrequently  contains  albumen,  particularly  in  severe 
cases,  but  this  is  by  no  means  indicative  of  corresponding  changes  in  the 
renal  structure;  on  the  contrary,  this  may  be  found  after  death  to  be  appa- 
rently free  from  disease.  Simon3  examined  the  urine  in  three  well-marked 
cases  of  scurvy  occurring  in  Schonlein's  wTards  ;  two  were  men  between  thirty 
and  forty  years  of  age,  and  the  third  a  woman  who  had  been  delivered  a  few 
days  previously.  In  its  physical  characters  the  urine  was  very  similar  in  the 
three  cases  ;  at  first  it  was  very  scanty  (8  to  12  oz.),  and  of  a  dark-brown 
color,  as  if  bile  pigment  or  decomposed  blood  were  present,  which,  however, 
was  not  the  case.  It  was  devoid  of  the  peculiar  sweetish  odor  of  typhus 
urine,  but,  after  standing  a  few  hours,  developed  a  disagreeable  ammoniacal 
odor.  There  was  a  deficiency  of  the  phosphates,  and  the  amount  of  urea  was 
much  less  than  in  normal  urine,  not  exceeding  20-30  per  cent,  of  the  solid 
residue. 

The  fixed  salts  were  diminished  in  the  urine  of  the  men,  forming  14-18  per 
cent,  of  the  solid  residue,  while  in  the  woman  they  amounted  to  27  per  cent,, 
a  little  above  the  normal  average  (25  per  cent.).  The  uric  acid  was  slightly 
above  the  healthy  standard  in  all  the  cases,  forming  1-3  per  cent,  of  the 
solid  residue. 

1   Himmelstiern,  Beohachtungen  iiber  den  Scorbut,  S.  50.     Berlin,  1S43. 

*  Prag.  Vierteljahrsschrift,  S.  153,  1861.  3  Chemistry  of  Man,  p.  320. 


300  SCURVY. 

Krebel1  states  that  the  urine  is  at  first  cloudy  and  brown,  afterwards 
becoming  decomposed  and  offensive,  and  an  oily  scum  forming  upon  it. 
Duchek2  dissents  from  this  statement,  and  asserts  that  in  slight  cases  the 
urine  in  its  physical  properties  is  unaltered  ;  and  that  in  aggravated  cases  it 
is  generally  of  a  deeper  color,  somewhat  decreased  in  quantity,  as  happens 
usually  in  fevers,  and  always  of  an  acid  reaction.  The  quantity  is  diminished 
to  from  1200  to  1500  cubic  centimetres,  and  in  very  severe  eases  is  as  low  as 
830  cubic  centimetres ;  the  specific  gravity  runs  as  low  as  1015  to  1009,  and 
the  quantity  of  all  the  solid  constituents  is  diminished,  with  the  exception  of 
phosphoric  acid  and  potassa,  the  latter  being  in  proportion  to  the  soda  as  1 
to  1.9,  while  in  health  it  bears  the  proportion  of  1  to  12.  As  recovery  pro- 
gresses, the  quantity  of  both  urine  and  its  solid  constituents  increases,  with 
the  exception  of  the  potassa  which,  on  the  contrary,  decreases.  Chalvet's 
analysis  of  the  urine,  from  a  well-developed  scorbutic  subject,  furnished  the 
following  result : — 


Water 950.50 

Solid  matters 49.50 

Urea         .  9.  (JO 

Extractive  12.60 

Albuminoid  matter           ........  7.50 

Mineral  matter 19.50 


( 

Matter  soluble  in  absolute  alcohol  .         .         .        < 


The  conclusions  that  would  seem  to  be  authorized  by  the  statements  of 
these  various  authorities,  are  that  the  quantity  of  urine  passed  is  decreased, 
as  well  as  that  of  the  urea,  while  the  amounts  of  the  albuminoid  and  mineral 
matters  are  increased. 

Physical  examination  will  reveal  the  frequent  occurrence  of  enlargement  of 
the  spleen,  independent  of  malarial  influences,  and  Krebel  has  encountered  one 
case  in  which  the  liver  was  involved  in  inflammation.  Some  derangement 
of  the  visual  organs  is  present  in  numerous  cases.  Dr.  Foltz,  in  the  epi- 
demic on  the  Raritan,  reported  four  cases  of  nyctalopia  and  two  of  hemera- 
lopia,  and  other  affections  of  the  eye,  such  as  conjunctivitis,  induration  and 
irritation  of  the  ciliary  margins  of  the  lids,  with  a  copious  and  acrimonious 
discharge,  these  conditions  being  obviously  due  to  the  scorbutic  diathesis. 
Hemorrhage  may  occur  under  the  conjunctiva,  raising  it  into  small  pouches ; 
into  the  anterior  chamber,  causing  iritis  and  adhesions  ;  and  finally  into  the 
choroid  and  vitreous  humor,  exciting  a  general  inflammation  of  the  entire 
organ.  Dulness  of  hearing  and  buzzing  in  the  ears  have  also  been  signalized 
as  occasional  symptoms  of  scurvy. 

The  phenomena  of fever  are  always  absent  during  the  course  of  uncompli- 
cated scurvy,  the  temperature  of  the  mouth  sometimes  falling  as  low  as  92° 
F. ;  and  being  always  one  or  two  degrees  lower  than  normal.  It  is  only  in 
th<'  later  periods  of  the  disease,  when  pathological  processes  most  often  super- 
vene in  the  internal  organs,  that  an  elevated  temperature  and  the  other  ordi- 
nary symptoms  of  fever  arc  manifested.  The  lowered  vital  resistance  of 
scorbutic  subjects  particularly  disposes  them  to  the  incursions  of  other 
fevers,  especially  those  of  malarial  and  typhoid  types;  hence  in  the  low, 
marshy  districts  of  northern  Europe,  and  in  seel  ions  of  country  afflicted  by 
famine  and  overcrowded  dwellings,  these  complications  are  very  common. 

'  TVr  Scorbnt,  S.  150. 

2  Zeitschrift  der  k.  k.  Gesellscliaft  der  Aerzte  zu.  Wien,  Bd.  i.  S.  56. 


DIAGNOSIS   AND   PROGNOSIS   OF   SCURVY.  301 


Diagnosis  of  Scurvy. 


The  recognition  of  scurvy  is  not  surrounded  by  any  embarrassing  difficul- 
ties, as  its  exclusive  etiological  character,  the  altogether  special  circumstance's 
of  its  occurrence,  the  peculiar  location  of  the  disease  in  the  various  tissues, 
and  the  establishment  of  the  preliminary  cachexia,  with  the  peculiar  dull, 
earthy  hue  which  subsequently  merges  as  it  advances  into  a  deeper  and  cya- 
notic tint,  point  with  unerring  certainty  to  its  identification.  It  is  rarely  re- 
stricted to  isolated  cases,  but  invades  groups  of  individuals,  or  communities 
living  under  similar  or  identical  hygienic  conditions,  as  occurs  on  board  ships, 
in  prisons,  in  armies,  in  places  closed  by  siege,  or  in  districts  of  country 
afflicted  with  common  calamities.  Single  cases  are,  however,  occasionally  met 
with,  and  I  have  myself  observed  one,  in  the  person  of  a  man  who  from  penu- 
rious motives  had  abstained  from  all  but  the  cheapest  and  coarsest  articles  of 
diet,  subsisting  chiefly  on  refuse  food  of  an  animal  character,  purchased  in  the 
markets  and  made  up  into  soups.  The  disease  was  at  first  supposed  to  be 
purpura  hemorrhagica,  until  the  above  mentioned  facts  were  discovered  and 
a  closer  inspection  made  of  the  variously  colored  spots ;  the  persistent  and  severe 
pains  in  the  limbs  and  back,  the  swollen  joints,  ulcerated  gums  and  fetid 
breath,  then  led  to  a  correct  conclusion,  and  the  man  soon  recovered  under 
dietetic  treatment.  The  same  conditions,  in  individual  cases,  will  enable  the 
observer  to  make  a  correct  discrimination  of  scurvy  from  other  pathological 
states  involving  hemorrhagic  extravasations  into  the  tissues,  such  as  occa- 
sionally occur  in  ansemia,  chlorosis,  leucocythaunia,  pseudo-leucremia,  perni- 
cious anaemia,  and  hemophilia.  These  never  occur  except  in  isolated  instances, 
while  scurvy,  as  stated  before,  is  rarely  seen  except  as  afflicting  numerous 
persons  at  the  same  time.  In  the  former  diseases,  also,  the  gums  never  pre- 
sent, although  they  may  be  tender'  and  disposed  to  bleed,  the  peculiar  color 
and  sponginess  characteristic  of  scurvy.  An  error  might,  however,  creep  in 
here  if  we  were  to  depend  solely  upon  this  phenomenon,  for  cases  of  scurvy 
have  been  reported  in  which  this  condition  did  not  exist,  and  it  does  not 
occur,  as  already  remarked,  in  edentulous  persons.  The  state  of  the  gums  in 
leucocythoemia,  it  has  been  said,  occasionally  approximates  this  condition,  but 
the  other  associated  symptoms  would  suffice  to  differentiate  that  disease  from 
scurvy. 

The  rapid  improvement  of  scurvy  under  fresh  vegetable  diet,  will  also  pre- 
sent a  striking  feature  not  encountered  in  anaemic  and  purpuric  cases.  In  the 
commencement  of  an  outbreak,  the  rheumatoid  pains,  so  common  in  the  back 
and  Jimbs  in  the  severe  cases,  have  caused  them  to  be  confounded  with  rheu- 
matism ;  inquiries  into  the  condition  of  the  gums  and  skin  will  readily  dispel 
this  error. 

Finally,  in  none  of  the  diseases  with  which  it  is  possible  to  confound  scurvy, 
do  we  meet  with  the  same  complications  of  vital  organs :  fibrinous  and  bloody 
effusions  among  the  muscles,  and  into  the  pleura^  pericardium,  peritoneum, 
and  synovial  sacs  of  the  joints;  deformities  of  the  limbs  from  contraction  of 
tendons;  and  distorted  joints  from  the  plastic  outpourings  about  them.  All 
of  these  features  are  special  to  scurvy,  and  serve  to  complete  a  clinical  picture 
altogether  characteristic  and  distinctive. 


Prognosis  of  Scurvy. 

The  prognosis  of  scurvy  will  depend  upon  the  stage  of  the  disease,  its  grade 
of  intensity,  its  complications,  the  constitutional  power  of  the  patient,  and  the 


302  SCURVY. 

nature  of  the  attendant  circumstances — particularly  the  possibility  or  not  of 
changing  or  ameliorating  the  hygienic  surroundings.  In  the  earlier  stage  of 
the  disease,  recovery  under  proper  treatment  is  assured;  and  it  is  remarkable 
how  soon  the  spongy  gums  and  discolorations  of  the  surface  will  recede,  and 
the  patient  regain  strength  and  cheerfulness.  Even  in  cases  of  notable  in- 
tensity, unaccompanied  by  involvement  of  the  internal  organs  or  serious  com- 
plication with  other  maladies,  the  prognosis  is  very  hopeful  when  the  patient 
can  be  put  under  favorable  influences.  Yet  it  must  be  said  that  often  appa- 
rently slight  cases  do  not  recover  as  rapidly  as  others  which  are  seemingly, 
from  external  appearances,  much  more  severe.  Complicated  cases,  with  im- 
plication of  the  thoracic  or  abdominal  viscera,  where  these  conditions  have 
entailed  no  considerable  effusions,  though  more  unfavorable  than  the  preceding 
groups,  are  still  amenable  to  well-directed  therapeutic  measures.  The  same 
conditions,  however,  linked  with  abundant  outpourings  of  serum  and  blood 
into  the  pleural,  pericardial,  and  abdominal  cavities,  are  exceedingly  unfavor- 
able, and  bode  a  mortal  issue.  Excessive  and  frequent  hemorrhages  are  liable 
to  bring  on  speedy  death  by  syncope ;  epistaxis  was  at  an  early  period  con- 
sidered a  mortal  sign,  and  one  necessarily  fatal.  Colliquative  diarrhoea  and 
dysentery  exhaust  the  strength  rapidly,  and  induce  a  fatal  issue  by  causing 
early  and  profound  prostration,  or  by  their  continuance  lead  to  the  same  result 
through  gradual  asthenia.  Persons  weak  and  feeble,  either  constitutionally 
or  from  the  inroads  of  prolonged  disease,  especially  of  a  malarial  character, 
from  a  previous  attack  of  scurvy,  or  from  other  cachectic  complaints,  are  less 
apt  to  recover  than  those  of  an  opposite  character.  The  attendant  circum- 
stances have  also  an  important  influence  on  the  prognosis.  On  shore  it  is 
easier  to  secure  good  accommodations,  with  dry,  well-ventilated,  and  clean 
apartments,  and  abundant  supplies  of  fresh  vegetable  food  and  other  desirable 
forms  of  nourishment,  than  on  the  sea;  in  long  voyages,  or  in  exploring  par- 
tics  into  the  interior  of  unknown  countries  or  in  high  latitudes,  it  may  be 
impossible  to  control  to  any  considerable  degree  these  indispensable  require- 
ments for  the  recovery  of  the  sick,  and  the  outlook  will  be  gloomy  indeed  for 
successful  treatment  of  even  the  mildest  cases. 


Treatment  of  Scurvy. 

There  is  no  disease  within  the  whole  range  of  pathology  which  yields  such 
satisfactory  results  to  well-directed  and  judicious  treatment  as  does  scurvy ; 
and  this  is  all  the  more  gratifying  when  it  is  remembered  that,  during  its 
period  of  rifeness  from  the  14th  to  the  18th  century,  it  did  more  destruction 
t<»  armies  and  fleets  than  the  sword  of  the  enemy  and  the  other  dangers  of 
warfare  combined.  Equally  as  remarkable  results  in  warding  oft'  the  disease 
attend  the  intelligent  adoption  of  the  prophylactic,  hygienic  measures  which 
experience  has  shown  in  multitudinous  instances,  through  a  long  period  of 
time  and  almost  everywhere,  to  be  indispensable  to  the  maintenance  of  health. 
A  cursory  consideration  of  tliese  measures  will  be  a  fitting  prelude  to  a  dis- 
cussion of  the  means  which  should  be  had  recourse  to  in  the  actual  invasion 
of  the  disease. 

Prophylaxis. — Groat  ameliorations  have  been  effected  during  the  last  cen- 
tury,  and  particularly  within  the  last  thirty  years,  in  the  physical  conditions 
under  which  the  sea-rarer  and  the  poor  in  northern  climates  live.  I3oth  house 
and  ship  hygiene  have  made  advances,  and  the  people  everywhere  enjoy  the 
fruits  resulting  therefrom,  in  possessing  better  lodgings,  greater  variety  of  food, 
purer  air,  more  comfortable  clothing,  and,  as  a  necessary  corollary  of  this,  a 


TREATMENT    OF   SCURVY.  303 

higher  moral  life  and  increased  happiness.  These  circumstances  have  limited 
scurvy  to  a  restricted  prevalence  on  board  of  badly-equipped  merchant  vessels, 
in  long  passages  ;  among  exploring  parties  in  high  latitudes  ;  in  armies  during 
time  of  war, cursed  with  an  incompetent  commissariat ;  and  occasionally  among 
the  inhabitants  of  besieged  towns.  It  has  been  attempted  by  legislation,  with 
more  or  less  success,  to  enforce  on  board  merchant  ships  the  adoption  of  the 
proper  hygienic  measures.  Such  laws  are  in  force  in  the  United  States,  in 
Great  Britain,  and  in  other  countries,  and  require  that  all  ships  shall  carry 
certain  articles  of  acknowledged  anti-scorbutic  power,  and  that  the  quarters 
of  the  men  shall  possess  a  requisite  amplitude.  In  the  equipment  of  arc-tic 
vessels,  proper  prevision  is  always  displayed  to  avert  the  invasion  of  scurvy 
during  such  service. 

The  greatest  import  attaches  to  an  unsparing  storing  up  of  fresh  vegetable 
and  animal  food,  which  should  always  be  provided  at  the  commencement  of  any 
voyage  likely  to  be  prolonged  for  several  months.  It  is  often  possible  to 
carry  live  animals  for  days  together,  and  the  stock  may  often  be  replenished 
at  the  different  ports  touched  at.  By  the  various  processes  of  canning,  pre- 
serving, drying,  etc.,  fresh  provisions  of  all  sorts  can  be  obtained,  that  may 
be  relied  on  as  capable  of  supplying  good,  wholesome  animal  food.  Eggs 
form  a  most  desirable  article  of  diet,  and  may  be  kept  good  for  months  by 
simple  methods  of  packing ;  and  their  nutritive  value  will  be  appreciated 
when  it  is  considered  that  a  single  egg  contains  as  much  nourishment  as  two 
ounces  of  fresh  beef.  Another  excellent  animal  food,  on  account  of  its  nutri- 
tive qualities  and  reported  efficiency  as  an  anti-scorbutic,  is  milk,  which,  when 
properly  prepared,  can  be  preserved  in  its  original  purity  and  with  undimin- 
ished nutritive  value,  indefinitely.  Vegetable  food  of  the  most  varied  cha- 
racter can  now  be  obtained  almost  anywhere,  and  a  ship  should  not  leave  port 
without  laying  in  a  stock  of  potatoes,  beets,  carrots,  cabbages,  and  fruits, 
which  should  be  regularly  served  out  as  part  of  the  ration.  With  a  very 
simple  contrivance,  quickly  growing  vegetables  may  be  successfull}7  cultivated 
on  shipboard.  The  plants  most  suitable  for  this  purpose  are  the  mustard, 
cress,  radish,  turnip,  etc. ;  cresses  and  mustard  are  the  most  rapid  growers. 
Almost  as  efficient  representatives  of  these  fresh  products  of  the  garden  are 
the  same  articles  prepared  in  various  ways,  and  put  up  in  tin  and  glass  vessels, 
and  when  the  former  are  not  procurable  these  should  be  substituted  in  the 
ration.  Sauerkraut  can  be  kept  indefinitely  in  any  climate,  and  has  deserv- 
edly enjoyed  reputation  as  a  good  anti-scorbutic,  while  it  is  cheerfully  received 
by  the  sailor  in  his  ration.  Desiccated  potatoes  have  been  found,  after  several 
years'  trial  in  the  navy,  to  possess  neither  much  food  value,  nor  to  be  at  all 
palatable,  and,  when  served  out,  have  as  a  rule  been  thrown  away,  so  that 
other  preparations  should  be  preferred.  Canned  tomatoes  are,  on  the  other 
hand,  eagerly  accepted,  and  are  much  esteemed  by  the  men.  Cheese  and  oat- 
meal would  also  be  desirable  additions  to  the  ordinary  allowance. 

The  value  of  lime-juice  as  a  preventive  of  scurvy  was  long  since  known, 
yet  it  was  not  made  a  part  of  the  English  navy  ration  until  1795,  when  it 
was  regularly  served  out.  The  merchant  shipping  act  of  England  requires  a 
supply  to  be  carried  by  all  merchant  vessels,  and  it  is  ordered  to  be  served  out 
daily  after  the  crew  has  been  ten  days  on  salt  food.  The  juice  readily  under- 
goes change,  if  not  prepared  with  the  greatest  caution,  and  particularly  on 
exposure  to  the  air;  on  this  account  it  ought  to  be  carried  in  glass  receivers 
of  from  one  to  two  gallons  each,  instead  of  casks  or  large  vessels,  so  that  one 
or  two  servings  may  exhaust  the  contents.  Ordinarily  the  juice  is  mixed  with 
10  per  cent,  of  spirit.  These  circumstances  have  rendered  it  desirable  to  have 
a  preparation  of  the  juice  in  some  more  concentrated  and  permanent  form.    Dr. 


304  SCURVY. 

Lind1  recommended  a  preparation  of  this  sort,  many  years  ago,  under  the 
name  of  "Rob."  The  very  concentrated  juice  may  also  be  preserved  in  gly- 
cerine, or  in  a  solid  form  as  a  lozenge  or  biscuit.  Malt,  originally  proposed 
by  Dr.  MacBride,  on  theoretic  grounds,  was  highly  esteemed  by  Captain  Cook 
as  a  preventive,  under  the  form  of  sweet  wort.  So,  too,  did  he  think  well  of 
the  Scotch  dish  called  "  sowens,"  prepared  by  concentrating  the  liquid  result- 
ing from  the  fermentation  of  oatmeal.  Cider  is  also  possessed  of  acknowl- 
edged anti-scorbutic  power. 

It  is  a  matter  of  importance  not  to  fail  in  issuing  good  potable  water  to  the 
crew,  and  fortunately  this  desideratum  is  now  fully  secured  on  war  vessels  by 
the  distilling  apparatus  with  which  they  are  supplied.  In  the  mercantile 
marine,  the  dependence  is  chiefly  upon  the  shore  supply,  which  should  be  in- 
spected as  to  quality  before  being  received.  The  general  qualities  of  water 
as  to  potability  may  be  roughly  tested  by  an  intelligent  person  by  simple 
chemical  means.  An  important  adjunct  in  preserving  health  in  long  voyages, 
is  a  good  wardrobe  of  clothes  suitable  to  the  sudden  and  severe  atmospheric 
vicissitudes ;  warm  woollen  underclothing  and  stout  cloth  suits,  for  stormy 
weather  and  the  cold  of  high  latitudes.  The  greatest  care  should  be  exer- 
cised to  avoid  sleeping  in  wet  garments,  and  when  these  have  been  removed, 
they  should  be  dried  without  delay.  The  sleeping  apartments  of  the  crew 
should  always  be  kept  scrupulously  clean  and  dry,  and  at  the  same  time  sup- 
plied with  the  requisite  quantity  of  pure  respirable  air,  and,  if  possible,  abund- 
ant sunlight.  It  is  unnecessary  to  do  more  than  cursorily  remark  that  all 
possible  means  should  be  adopted  to  sustain  a  cheerful  disposition  among  the 
crew,  encouraging  the  use  of  musical  instruments,  games,  and  social  gatherings 
on  proper  occasions.  Attention  to  the  foregoing  circumstances :  varied  diet, 
wholesome  water,  suitable  clothing,  and  comfortable,  well-ventilated  quarters, 
will  assure  the  utmost  security  against  the  occurrence  of  scurvy,  either  on 
shipboard  or  on  the  land.  There  is  really  no  difference  in  this  respect,  as  the 
same  hygienic  provisions  apply  equally  to  the  soldier  and  sailor,  and  to  the 
occupants  of  crowded  eleemosynary  and  penal  establishments. 

Curative  Treatment. — In  the  management  of  the  disease  therapeutically, 
the  first  consideration  is  to  amend  the  diet,  if  possible,  supplying  fresh  meats, 
soups,  or  other  nitrogenous  food  in  a  readily  assimilable  form,  and  recent 
vegetables ;  the  chief  of  the  domesticated  varieties  of  these  are  cabbages, 
beets,  radishes,  turnips,  carrots,  and  potatoes ;  others,  growing  wild,  are  sorrel, 
cresses,  taraxacum,  nasturtium,  mushrooms,  garlic,  mustard,  scurvy  and  com- 
m<  >n  grass,  and  the  tops  of  the  spruce.  These  are  attainable  almost  everywhere, 
and  some  even  in  the  hyperborean  regions.  The  ancient  Celt  used  the  com- 
mon shamrock  as  food.  The  useful  fruits  are  those  of  an  acescent  character, 
and  the  juices  of  the  lime,  lemon,  and  orange,  hold  deservedly  the  first  rank. 
When  these  are  not  attainable,  apples,  pears,  grapes,  cherries,  and  currants 
will  be  of  decided  advantage.  The  vegetable  acids,  citric,  tartaric,  and  acetic, 
their  combinations  with  potassium,  and  the  acescent  wines  will  be  of  service. 
]  >r.  1  Vrin2  found  in  his  experience  the  expressed  juice  of  the  Maguey,  or  Agave 
Americana,  superior  to  all  other  anti-scorbutic  remedies,  not  excepting  lime- 
juice.  Nitrate  of  potassium,  either  alone  or  mixed  with  vinegar,  has  been 
lauded  as  an  anti-scorbutic.  It  is  remarkable  how  rapidly  the  most  painful 
and  even  threatening  symptoms  melt  away,  as  it  were  by  magic,  under  this 
dietetic  treatment  alone.  In  cases  associated  with  debility,  or  tardy  in  con- 
valescence, the  bitter  and  aromatic  tonics,  quinine,  gentian,  etc.,  either  alone 
(■I-  combined  with  ferruginous  preparations,  and  the  mineral  acids,  will  be 

1  Treatise  on  the  Scurvy.  «  Medical  Statistics,  U.  S.  Army,  1839-54,  p.  362. 


CURATIVE    TREATMENT.  305 

indicated,  as  well  as  beer  and  wine.  Derblich1  records  his  belief  that  the  tinc- 
ture of  cantharides  exercises  almost  specific  effects  in  the  treatment  of  scurvy. 

In  meeting  complications,  appropriate  remedies  will  be  found  for  the  scor- 
butic stomatitis  in  the  mineral  and  vegetable  astringents,  washes  containing 
carbolic  acid,  and  solutions  of  chlorinated  lime  or  permanganate  of  potassium"; 
a  solution  of  nitrate  of  silver  also  yields  good  results.  These  various  reme- 
dies will  afford  relief,  but  no  permanent  improvement  will  ensue  without  the 
consentaneous  adoption  of  vegetable  food.  The  alterations  in  the  skin  demand 
no  particular  treatment,  unless  ulceration  has  occurred,  when  the  use  of  sooth- 
ing applications,  and  protection  from  sources  of  external  irritation,  will  be 
indicated ;  while  at  the  same  time  the  parts  must  be  kept  perfectly  clean  and 
free  from  offensive  odor  by  the  use  of  chlorinated  or  carbolated  washes.  In 
the  hemorrhagic  complications,  the  same  treatment  will  be  indicated  as  in  simi- 
lar conditions  unaccompanied  by  scurvy.  Epistaxis  may  be  checked  by  cold 
applications  to  the  head,  and  by  making  the  patient  snuff  astringent  powders, 
such  as  tannin,  powdered  rhatany,  etc.  In  serious  cases,  plugging  of  the  nares 
must  be  promptly  adopted.  Hemorrhage  from  the  stomach  or  bowels  is  to  be 
checked  by  the  external  use  of  cold  cloths,  or  ice,  to  the  abdomen,  and  by  the 
internal  administration  of  ergot,  tincture  of  the  chloride  of  iron,  gallic  acid, 
acetate  of  lead  and  opium,  or  other  agents  of  the  haemostatic  class.  Effusions 
of  blood  or  sero-sanguinolent  fluid  into  the  pericardium  or  pleura,  if  not 
excessive,  will  generally  recede  as  the  general  condition  improves  under  the 
treatment  already  indicated.  Should  the  quantity,  however,  increase  to  such 
a  degree  as  to  embarrass  the  circulation  and  respiration,  there  is  no  alternative 
left  but  paracentesis,  which  at  most  affords  slender  chances  for  recovery. 

In  the  management  of  this  disease,  an  important  indication  is  to  have  the 
patient  so  watched  that  he  may  not  be  permitted  to  perform  any  movement 
likely  to  throw  an  additional  burthen  upon  an  already  overtaxed  heart ;  it 
has  happened,  time  and  again,  that  assuming  the  erect  posture  suddenly,  or 
ascending  a  few  steps,  has  resulted  in  immediate  death.  The  strength  must 
be  taxed  neither  by  active  catharsis  nor  by  bloodletting ;  should  the  bowels 
need  moving,  the  gentlest  laxatives  will  suffice  to  secure  the  desired  effect. 
All  preparations  of  mercury  should  be  avoided,  as  they  exercise  the  most 
pernicious  effects,  especially  when  carried  to  the  extent  of  salivation.  The 
evil  results  of  these  remedies  were  lamentably  shown  in  the  wholesale 
slaughter  of  four  hundred  men  as  reported  by  Kramer. 

1  Wiener  medizinische  Wochenscrift,  1S61,  S.  827. 


VOL.  I.— 20 


THE  RECIPROCAL  EFFECTS  OF  CONSTITUTIONAL 
CONDITIONS  AND  INJURIES. 


BY 

A.  YERNEUIL,  M.D., 

PROFESSOR  OF  CLINICAL  SURGERY  IN  THE  FACULTY  OF  MEDICINE,   PARIS. 


It  is  yet  very  difficult  to  establish  in  an  exact  and  complete  manner  the 
relations  existing  between  constitutional  conditions  and  traumatic  lesions,  but 
even  now,  by  the  aid  of  the  literature  hitherto  collected,  we  have  (1)  acquired 
very  useful  ideas  in  regard  to  the  diagnosis,  prognosis,  and  treatment  of  inju- 
ries which  occur  as  the  results  of  surgical  or  accidental  wounds,  and  (2)  for- 
mulated much  more  distinctly  the  indications  and  contra-indications  for 
operation  in  individuals  affected  by  previously  existing  constitutional  states. 
If  we  consider  how, much  has  already  been  done  in  this  direction,  despite  the 
short  time  since  these  studies  have  been  begun,  and  the  very  small  number  of 
authors  who  have  investigated  them,  we  may  be  assured  that  they  will  render, 
before  the  end  of  the  present  century,  considerable  service  to  medical  science 
and  to  the  art  of  surgery.  Before  entering  directly  into  this  question,  it  will 
be  useful  to  define  what  I  mean  by  constitutional  diseases,  and  to  indicate 
their  number  and  their  classification. 

A  constitutional  disease,  clearly  represented  by  the  old  expression  morbus 
totias  substantia?,  and  which  may  be  more  concisely  termed  panpathy ;  a  con- 
stitutional disease,  I  say,  affects  at  the  same  time  all  the  organic  fluids  and 
solids,  altering  the  latter  more  than  the  former,  or  vice  versa  ;  modifying  by 
preference  this  fluid,  or  affecting  this  system,  rather  than  others  ;  but  at  a 
given  moment  involving  the  entire  economy.  The  number  of  these  diseases 
has  been  sometimes  too  much  restricted,  sometimes  too  much  extended,  and 
a  reform  must  be  attempted  in  this  respect.  I  shall  content  myself  with 
drawing  up  a  list  into  which  may  enter  all  those  which  are  already  known, 
or  which  are  yet  to  be  recognized. 

_  (1)  Diseases  of  nutrition,  usually  hereditary,  but  also  acquired :  arthritism 
(including  gout  and  rheumatism) ;  undoubtedly  cancer ;  scrofula  (including 
the  large  majority  of  cases  of  tuberculosis). 

(2)  Poisons  of  external  origin :  syphilis,  malaria,  alcoholism,  morphinism, 
saturnism  [lead  poisoning],  glanders,  heterochthonous  septicaemias;  or  of  in-\ 
ternal  origin :  diabetes,  leukaemia,  autochthonous  septicaemias. 

(3)  General  conditions  following  sooner  or  later  on  a  permanent  lesion  of  an 
important  viscus,  such  as  the  lungs,  heart,  liver,  kidneys,  brain,  spinal  cord, 
etc.  Although  presenting  the  fundamental  characteristics  of  constitutional 
diseases,  these  conditions  have  not  yet  received  a  special  name.     It  is  only 

(307  ) 


308        RECIPROCAL   EFFECTS   OF   CONSTITUTIONAL   CONDITIONS   AND   INJURIES. 

recently  that  those  suffering  from  them  have  been  called  cardiac,  hepatic, 
nephritic  subjects,  etc.  Old  age,  as  a  permanent  general  condition  character- 
ized by  various  degenerations  of  the  viscera  (steatosis,  sclerosis),  pregnancy, 
the  puerperal  state,  and  acute  anosmia,  being  temporary  extra-physiological  con- 
ditions, may  enter  into  this  category. 


On  the  Reciprocal  Influence  of  Constitutional  Conditions  and  Injuries. 

Pre-existing  or  propathic  general  conditions  may  exercise  an  influence  upon 
injuries  in  various  ways : — 

Primarily,  by  favoring  the  development  of  certain  complications  which  are 
situated  at  the  site  of  injury,  or  start  from  it ;  inflammation,  circumscribed 
or  diffuse  ;  lymphangeitis  ;  erysipelas  ;  hemorrhage ;  neuralgia ;  alteration  of 
the  granular  membrane,  etc. 

Secondarily,  by  modifying,  arresting,  and  disturbing  the  reparative  pro- 
cess ;  by  destroying  what  has  already  been  accomplished  (ulceration  of  cica- 
trices, softening  of  callus);  by  replacing  an  affection  of  a  determinate  and 
calculable  duration,  the  trauma,  by  another  affection  the  length  of  which  we 
are  unable  to  foresee. 

Finally,  by  fixing  themselves  upon  the  point  already  wounded  and  become 
the  place  of  least  resistance  (locus  minoris  rcsistcntia?),  in  order  to  develop  there 
a  more  or  less  obstinate  diathetic  manifestation. 

On  the  other  hand,  traumatism  may  exercise  an  evident  action  upon  pre- 
existing constitutional  states  ;  it  may  call  them  to  the  wounded  spot,  awaken 
or  reawaken  them,  make  them  pass  from  a  latent  to  an  active  condition,  and 
cause  their  manifestations  to  appear  at  the  site  of  injury  itself,  or  in  distant 
regions,  if  not  throughout  the  entire  economy.  It  usually  hastens  the  course 
of  the  diathesis,  and  more  especially  aggravates  the  lesions  which  that  has 
already  produced,  and  which  may  have  been  more  or  less  stationary  before 
the  injury. 

But  this  is  not  true  of  all  cases.  The  constitutional  affection  and  the  in- 
jury may  at  first  run  parallel  to  each  other,  without  influencing  each  other  in 
the  least;  the  subject  of  the  diathesis  supports  the  shock  as  if  he  were  per- 
fectly healthy,  while  the  wound  on  the  other  hand  runs  a  regular  and  classical 
course.  These  fortunate  cases  are  not  very  rare;  we  are  beginning  to  be  able 
to  foresee  them,  and  we  shall  undoubtedly  soon  succeed  in  increasing  their 
proportion.  In  the  second  place,  the  influence  of  the  trauma  upon  the  con- 
stitutional disease  is  not  always  unfavorable,  but  rather  the  contrary  ;  for  the 
local  affection  may  perhaps  be  the  cause  as  well  as  the  effect  of  the  general 
malady,  in  which  event,  its  suppression  exercises  the  most  prompt  and  deci- 
sive action  up<  m  the  re-establishment  of  health.  It  is  in  this  way,  for  example, 
that  our  operations  act  so  effectually  against  chronic  septicaemias.  Finally, 
even  when  the  simple  or  reciprocal  influence  of  the  injury  upon  the  primary 
disease  is  exercised  in  an  unfavorable  manner,  the  resulting  morbid  actions 
are  not  always  very  disastrous. 

On  the  other  hand,  diatheses  only  have  a  limited  pathogenic  influence; 
accidental  causes,  including  injury,  can  only  make  them  produce  a  certain 
number  of  determinate  local  manifestations,  which  cannot  differ,  and  in  reality 
do  not  essentially  differ,  whether  they  have  been  produced  by  main  force,and 
as  it  were  unseasonably,  or  whether  they  have  been  developed  spontaneously 
in  consequence  of  the  natural  evolution  of  the  malady. 

From  a  clinical  point  of  view,  constitutional  diseases  present  numberless 
differences:  they  are  active  or  latent;  of  recent  date  or  of  long  standing;  of 
slow  or  of  rapid  course;  with  a  constant  tendency  towards  aggravation  or 


RECIPROCAL   INFLUENCE   OF   CONSTITUTIONAL    CONDITIONS   AND   INJURIES.   309 

towards  recovery;  capable  of  yielding  to  treatment  or  of  obstinately  resisting 
it ;  still  compatible  with  a  moderate  degree  of  health,  or  impairing  more  or 
less  deeply  the  more  important  functions  ;  sometimes  single,  sometimes  com- 
bined or  associated  with  one  another  in  such  a  manner  as  to  create  hybrid 
forms,  which  are  very  little  known  despite  their  extreme  frequency  and  great 
interest.  It  is  hardly  necessary  to  add  that  each  constitutional  disease  pre- 
sents mild  and  grave,  acute  and  chronic  varieties  ;  and  that  for  some  of  them, 
syphilis  and  scrofula  for  example,  stages  and  periods  are  properly  recognized. 
All  these  considerations  enable  us  to  understand,  a  priori,  that  operative  and 
accidental  traumata  cannot  have  a  uniform  action  upon  dissimilar  subjects, 
and  that,  on  the  other  hand,  different  diseases  cannot  react  in  the  same  man- 
ner upon  the  traumatic  process. 

But  observation  will  show  even  better  that  the  prognosis  of  operations 
varies  infinitely  in  one  or  another  panpathy,  because  each  constitutional  dis- 
ease interferes  with  the  reparative  process  in  its  own  way,  and  because  the 
same  surgical  wound  reacts  in  a  peculiar  manner  upon  each  particular  subject 
of  a  diathesis.  I  do  not  know  how  many  observations  would  have  to  be 
made,  nor  how  much  time  devoted  to  their  analysis,  before  making  a  gener- 
alization and  obtaining  exact  indications  for  practice ;  but,  in  the  mean  time, 
I  can  enunciate  certain  synthetic  remarks  which  I  believe  to  be  already  suf- 
ficiently firmly  established.  They  are  not  based  on  clinical  history,  but  on 
pathological  anatomy. 

Without  underestimating  the  large  gaps  which  this  important  branch  of 
medicine  still  presents  with  reference  to  general  diseases  (and  it  is  known  that 
this  reproach  is  emphasized  by  the  latest  representatives  of  the  purely  clini- 
cal school),  we  may  nevertheless  recognize  in  these  affections  three  distinct 
phases:  (1)  that  of  dyscrasia,  usually  opening  the  scene,  continuing  perhaps 
permanently,  and  representing  alone  the  morbid  condition;  characterized 
essentially  by  a  change  in  the  fluids,  which,  unfortunately,  we  are  still  far 
from  understanding  even  with  regard  to  the  most  frequent  diathesis  ;  (2)  that 
of  peripheral  lesions,  appeciable  to  the  chemist  or  pathological  anatomist,  but 
slight,  or  affecting  organs  of  secondary  importance  ;  and  finally  (3)  that  of  visce- 
ral lesions,  with  two  varieties  which  must  be  distinguished  according  as  the 
organs  are  affected  by  a  common  or  general  pathological  process — phlogosis, 
sclerosis,  cirrhosis,  steatosis,  amylosis;  or  are  the  site  of  a  heteromorphous 
deposit  peculiar  to  certain  general  diseases — tubercles,  gummata,  lithiasis, 
various  neoplasms. 

The  following  is  the  result  of  experience  derived  from  a  large  number  of 
cases  taken  from  my  own  practice  or  that  of  others :  in  the  purely  dyserasic 
•period,  the  patients  tolerate  operations  almost  as  well  as  healthy  subjects ; 
the  manifestations  of  constitutional  disease,  when  they  make  their  appear- 
ance, are  usually  of  little  gravity  and  but  temporary ;  and,  if  the  changes  of 
the  fluids  are  still  slight,  the  reparative  process  proceeds  with  sufficient  regu- 
larity. During  the  period  of  -peripheral  lesions,  the  reaction  of  the  trauma 
may  be  more  grave,  because  it  finds,  in  the  more  or  less  seriously  affected  tis- 
sues, systems  or  organs,  places  of  least  resistance,  thoroughly  prepared  for 
fresh  diathetic  manifestations  or  an  aggravation  of  the  pre-existing  disorders. 
Anomalies  in  the  local  process  are  to  be  so  much  the  more  dreaded,  as  the 
concomitant  dyscrasia  is  the  more  pronounced.  During  the  period  of  visceral 
lesions,  the  dangers  are  greatly  increased,  because  the  morbid  process  is  pecu- 
liarly complicated.  In  the  first  place,  the  sites  (loci)  of  least  resistance  being 
situated  in  organs  essential  to  life,  the  reaction  of  the  traumatism  upon  them 
gives  rise  to,  or  aggravates,  affections  regarded  as  serious  at  all  times  and  in 
every  case,  and  in  which  there  is  great  danger  to  life.  The  dyscrasia  too,  in 
its  turn,  reaches  its  height,  fostered  as  it  is  by  two  causes :  (1)  the  humoral 


310       RECIPROCAL    EFFECTS   OF   CONSTITUTIONAL    CONDITIONS   AND   INJURIES. 

changes  due  to  the  constitutional  disease,  and  (2)  that  other  adulteration  of 
the  fluids  which  inevitably  results  from  imperfect  or  perverted  function  of 
an  important  viscus ;  hence  conditions  which  are  extremely  unfavorable  for 
the  progress  of  the  trauma  towards  recovery.  I  believe  also  that  I  can  point 
out  a  third  source  of  danger  which  has,  I  think,  hitherto  passed  unnoticed. 
The  injured  region,  it  is  commonly  believed,  is  capable  of  developing  an 
organic  poison,  the  entrance  of  which  into  the  economy  produces  a  true 
intoxication,  viz.,  traumatic  septicaemia.  The  latter  is  of  variable  intensity, 
according  to  the  quality  or  quantity  of  the  poison,  its  accumulation  or  elimi- 
nation. Under  ordinary  conditions  and  in  healthy  subjects,  the  large  viscera 
serve  as  emunctories  for  this  poison  as  for  so  many  others.  But  if  this  vent 
be  closed  on  account  of  a  profound  lesion  of  the  glandular  parenchymata, 
elimination  is  rendered  impossible,  and  those  acute  septicaemias  are  found  to 
be  developed  which  so  rapidly  lead  to  death. 

All  these  propositions  would  gain  in  clearness  by  being  sufficiently  de- 
veloped or  illustrated  by  examples,  and  I  greatly  fear  that  they  will  not  be 
understood  in  the  concise  shape  under  which  I  present  them ;  but  I  am 
limited  as  to  space,  and  cannot  dilate  further  upon  this  part  of  the  subject. 

The  conduct  of  the  surgeon  follows  naturally  from  what  has  gone  before. 
Since  the  subjects  of  diatheses  cannot  be  deprived  of  the  benefits  of  surgical 
interference,  even  though  this  be  particularly  dangerous  to  them,  the  surgeon 
should  strive  to  lessen  the  gravity  of  the  prognosis,  and  to  insure  at  least 
operative  success,  that  is,  the  immediate  result  of  his  operation.  In  cases  in 
which  he  cannot  do  this,  he  had  better  abstain,  unless  indeed  he  does  not  seek 
the  cure  of  the  disease,  and  is  content  with  merely  checking  its  progress. 
Fortunately,  he  will  often  succeed  in  averting  the  accidents  which  arise  from 
the  constitutional  condition,  by  the  aid  of  a  series  of  readily  executed  measures. 

In  the  first  place,  he  will  carefully  choose  his  time.  If  this  is  impractica- 
ble in  urgent  cases,  the  rule  of  occasio  prcccej)s  is,  on  the  contrary,  easily  fol- 
lowed when,  life  not  being  immediately  threatened,  we  can  hasten  or  delay 
the  time  of  action.  As  regards  the  majority  of  morbid  states,  we  should  ope- 
rate quickly,  during  the  dyscrasic  period,  before  the  onset,  of  the  histological, 
and  especially  of  the  visceral  lesions.  In  the  two  chief  constitutional  dis- 
eases, arthritism  and  scrofula,  the  latent  period  is  preferable  to  that  in  which 
fresh  manifestations  occur.  We  may  allow  certain  diatheses,  like  syphilis, 
to  wear  themselves  out ;  but,  on  the  other  hand,  we  should  attack  at  the  onset 
those  neoplasms  which  are  still  local,  and  the  extension  and  generalization  of 
which  are  imminent. 

Great  care  should  be  taken  with  regard  to  the  operative  procedure.  We 
must  be  very  sparing  of  blood  in  exhausted  or  poisoned  subjects;  must  save 
neuropathic  individuals  as  much  pain  as  possible  ;  and  must  prevent,  as  much 
as  we  can,  traumatic  fever  in  those  whose  viscera  are  affected.  An  excep- 
tional and  little  used  method  may  become  the  plan  of  election  in  a  particular 
instance.  Diabetic  phlegmons  and  carbuncles  should  be  incised  by  the  thermo- 
cautery and  hot  iron,  not  with  the  bistoury.  Methods  of  slow  and  progressive 
division  would,  on  the  contrary,  be  injurious  in  irritable  subjects,  whom  pain 
exhausts  and  irritates. 

The  choice  <>!'  a  dressing  also  merits  special  attention.  I  may  remark,  in  the 
firsl  place,  thai  diathetic' patients,  like  all  others,  owe  thanks  to  the  antisep- 
tic method.  Whenever  possible,  the  judicious  employment  of  various  forms  of 
this  method:  the  wadding  dressing  of  Alphonse  Guerin,  Lister's  dressing,  the 
open  antiseptic  dressing,  etc.,  counterbalance  to  a  considerable  extent  the 
unfavorable  influences  of  constitutional  diseases.  Under  the  wadding 
bandage,  1  have  seen  alcoholics  and  diabetics  recover,  who  would  almost  un- 
doubtedly have  succumbed  ten  years  ago  with  the  old-fashioned  dressings.     I 


ARTHRITISM.  oil 

bare  obtained  wonderful  results  with  tbe  permanent  antiseptic  bath  and  with 
open  dressings.  Lister  and  his  disciples  daily  perform  similar  miracles  which 
throw  into  relief  the  great  part  played  by  the  traumatic  centre  in  the  produc- 
tion of  complications.  AVe  must  not,  however,  run  into  extremes ;  and  in 
considering  how  very  favorable  is  the  suppression  of  traumatic  fever  in  dia- 
thetic individuals,  we  must  not  imagine  that  all  danger  ceases  from  merely 
treating  the  wounds  antiseptically.  If  this  were  so,  the  influence  of  constitu- 
tional conditions  would  be  entirely  neutralized  to-da}T,  and  these  pages  would 
be  unnecessary. 

I  know  not  whether  in  the  future  affairs  will  run  such  a  course  that  we 
need  not  fear  the  deterioration  of  the  economy  by  antecedent  diseases,  hut 
unfortunately  we  have  not  arrived  at  that  stage  at  present.  With  the  anti- 
septic method  we  lose  indeed  fewer,  many  fewer  patients  ;  but  we  still  lose 
some,  and  a  careful  examination  of  the  causes  of  death  clearly  shows  us  that 
they  consist  almost  exclusively  in  bad  constitutional  conditions  of  the  injured 
persons.  We  may  add,  moreover,  that  antiseptic  dressings,  in  order  to  be 
really  efficacious,  should  be  applied  rigorously,  and  that  such  applications 
cannot  always  be  effected  in  the  actual  condition  of  science.  In  order  to 
prove  this,  it  is  only  necessary  to  refer  to  the  extensive  class  of  operations  in 
cavities,  that  we  may  remind  the  surgeon  that,  under  many  circumstances,  he 
must  still  combat-  the  evil  influence  of  general  disease. 

But  the  point  which  must  be  insisted  on  most  strongly,  is  the  necessity  of 
instituting  during,  after,  and  especially  before  the  operation,  if  there  be  no 
urgency,  a  plan  of  treatment  in  which  are  associated  hygiene,  diet,  the  use  of 
drugs — medical  treatment  par  excellence — designed  to  combat  the  constitu- 
tional disease,  as  would  be  done  were  no  surgical  complication  present.  Not 
only,  by  such  a  plan,  will  the  chances  of  the  immediate  success  of  the  opera- 
tion be  increased,  but  we  will  often  have  the  good  fortune  of  indefinitely 
delaying  the  injurious  relapses  of  the  diathesis.  It  may  even  happen  that, 
while  merely  attempting  a  preparation  which  shall  be  favorable  to  the  final 
result,  there  may  be  obtained,  by  medical  treatment  alone,  a  recovery  as  bril- 
liant and  much  less  onerous  than  that  which  was  expected  from  the  knife. 

After  these  general  considerations  upon  the  reciprocal  influence  of  consti- 
tutional diseases  and  traumatic  lesions,  we  will  now  begin  the  study  of  the 
relations  of  each  panpathy  to  wTounds. 


Arthritism. 
{Rheumatism,  Gout,  Herpctism.) 

Eheumatism. — (1)  Influence  of  Rheumatism  upon  the  Seat  of  Injury. — The 
rheumatic  diathesis  has  not,  like  syphilis  and  scrofula,  the  property  of  im- 
pressing a  peculiar  stamp  upon  the  traumatic  lesion  ;  it  does  not  even  modify 
to  an  appreciable  extent  the  reparative  process  as  do  alcoholism  and  diabetes. 
Neither  favoring  the  production  of  pus,  nor  counting  among  its  morbid  pro- 
cesses either  ulceration,  gangrene,  or  diffuse  inflammation,  it  has  hardly  any 
tendency  to  modify  surgical  wounds  unfavorably,  to  increase  or  alter  the  sup- 
puration, to  prevent  the  formation  and  transformation  of  the  granular  mem- 
brane. Open  wounds,  therefore,  have  commonly  a  good  appearance  in  rheu- 
matic patients,  and  run  their  course  in  the  usual  manner.  Certain  specific 
complications  may,  however,  occur  at  the  wounded  point,  which  are  observed 
not  unfrequently  and  are  easily  recognized.  It  is  known  that  even  a  slight 
articular  lesion  in  a  rheumatic  patient  readily  gives  rise  to  a  hydrarthrosis, 
a  more  or  les.«  obstinate  synovitis,  or  even  loose  bodies  ;  and  that  a  luxation,  a 


312       RECIPROCAL   EFFECTS   OF   CONSTITUTIONAL    CONDITIONS    AND   INJURIES. 

sprain,  a  penetrating  or  even  epiphyseal  fracture,  may  prematurely  give  rise 
to  the  characteristic  lesions  of  dry  arthritis,  and  sometimes  even  to  true  or 
false  anchylosis.  The  rheumatic  diathesis,  in  the  various  places  in  which  its 
spontaneous  manifestations  arise,  very  readily  and  rapidly  causes  serous  effu- 
sions, cedema,  plastic  exudations,  temporary  or  permanent  (under  the  form  of 
various  neoplasms — fibroma,  cancer,  etc.),  simple  or  hemorrhagic  congestions, 
all  accompanied  hy  severe  pains,  fixed  or  wandering,  temporary,  intermittent, 
remittent  or  continuous,  assuming  the  form  of  local  hyperesthesia  or  irra- 
diated neuralgia;  and,  on  carefully  watching  an  injured  rheumatic,  it  is  easy 
to  recognize  at  the  seat  of  injury,  or  in  its  immediate  neighborhood,  an  entire 
series  of  anatomical  lesions  of  functional  disorders,  having  the  greatest  resem- 
blance with  those  which  have  been  mentioned — lesions  and  disorders  which, 
to  my  mind,  constitute  the  arthritic  complications  of  wounds.  Among  these, 
for  example,  I  include  serous  effusions  in  cavities  or  connective  tissue,  marked 
cellular  proliferation,  pseudo-phlegmons,  active  hemorrhages,  erythema  and 
other  severe  eruptions  in  the  neighborhood  of  the  wound,  neuralgia,  and,  at 
a  later  period,  neoplasms  and  certain  affections  of  the  cicatrix. 

(2)  Influence  of  Injuries  upon  Rheumatism. — It  wTould  be  undoubtedly 
proper  to  distinguish  cases  according  as  the  injury  occurred  before,  during,  or 
after  the  rheumatic  attack ;  but  the  facts  are  wanting  for  the  carrying  out  of 
this  programme.  There  are  scarcely  any  observations  on  record  of  wounds 
contracted  during  an  attack  of  articular  rheumatism ;  those  of  wounds  prior 
to  the  first  rheumatic  manifestations,  and  which  produce  the  unexpected  and 
premature  appearance  of  the  diathesis,  are  equally  rare.  ^Nothing  is  more 
common,  on  the  contrary,  than  the  renewal  of  rheumatic  symptoms  of  older 
or  more  recent  date.  This  fact,  equally  well  known  to  the  physician  and 
surgeon,  has  been  recognized  in  a  summary  manner  for  a  long  time.  The 
wounds  which  may  excite  the  diathesis  are  extremely  varied ;  strains,  frac- 
tures, slight  or  serious  contusions,  the  most  varied  surgical  operations,  the 
removal  of  tumors,  incision  of  fistula?,  lithotomy  and  lithotrity,  etc.  In  their 
turn,  the  manifestations  of  the  diathesis  thus  reawakened,  are  no  less  variable ; 
sometimes  the  entire  economy  is  disturbed  by  a  fresh  attack  of  acute,  general- 
ized rheumatism,  sometimes  there  is  only  a  local  affection,  striking  a  part 
which  had  been  previously  involved,  without  this  predisposing  condition 
being  however  necessary.  We  find  recorded  cases  of  acute  or  chronic 
arthritis,  certain  cutaneous  eruptions  (herpes  among  others),  neuralgic  pains, 
muscular  spasms,  contractions,  pericarditis,  cystitis,  pulmonary  congestion, 
hepatic  or  nephritic  colic,  changes  in  the  urine,  profuse  sweats,  etc. 

Chronic  rheumatism  affecting  important  organs,  such  as  the  heart,  lungs, 
kidneys,  and  walls  of  vessels,  may  at  length  affect  their  structure  more  or  less 
profoundly,  and  convert  them  into  weak  points  which  will  feel  the  effects  of 
the  traumatism.  But  the  complications  which  then  arise  have  only  distant 
relations  with  rheumatism,  and  may  be  more  conveniently  studied  when  we 
come  to  the  special  consideration  of  the  constitutional  conditions  developed 
by  affections  of  the  great  viscera. 

Gout. — Like  rheumatism,  gout  generally  respects  the  reparative  process, 
and  usually  does  no1  interfere  with  the  cicatrization  of  wounds.  Neverthe- 
Li  -  it  is  sometimes  manifested  at  the  site  of  injury  by  fluxions  with  acute 
pains,  which  are  capable  of  simulating  frank  inflammation,  but  which  are 
cnly  congestions,  usually  of  a  temporary  character.  The  pain  also  occurs 
without  any  apparent  lesion,  and  under  the  form  of  neuralgia.  In  these  cases, 
indeed,  the  curative  process  is  temporarily  suspended  or  at  least  retarded. 
At  a  later  period,  chalk  stones  may  appear  around  wounded  joints,  and  in 
of  fracture  exuberant  callus  has  been  observed.     Repeated  slight  injuries 


CANCER.  31-3 

in  the  gouty  may  probably  have  for  their  effect  the  development  of  certain  neo- 
plasms, especially  epithelioma.  Subcutaneous  lesions  and  sprains  are  more 
liable  to  be  followed  by  manifestations  of  the  diathesis  than  open  wounds. 

The  traumatism  in  its  turn,  has  an  effect  upon  the  disease.  There  is  hardly 
any  example  known  of  an  injury  contracted  during  an  attack  of  gout,  or 
which  has  excited  the  first  attack  of  a  previously  latent  gout.  In  the  cases 
observed,  the  injury  occurred  in  the  interval  between  two  attacks,  in  a  gouty 
patient  who  had  previously  suffered  more  or  less  often.  As  a  rule,  the 
attacks  thus  provoked  by  main  force  develop  quickly  (from  the  first  to  the 
fourth  day  for  example),  are  of  but  moderate  intensity  and  brief  duration, 
and  appear  to  be  excited  preferably  by  slight  injuries.  I  have,  for  instance, 
twice  seen  gout  follow  puncture  of  a  hydrocele  with  a  very  fine  trocar.  In 
one  case  in  which  an  injection  of  iodine  had  been  made,  the  attack  appeared 
to  act  as  a  derivative,  for  the  inflammation  of  the  tunica  vaginalis  was  to  a 
great  extent  wanting,  causing  extreme  slowness  of  recovery.  In  cases  of 
chronic  gout  or  gouty  cachexia  in  gouty  subjects  affected  with  renal  or  he- 
patic lesions,  the  prognosis  is  rendered  grave.  More  or  less  serious  compli- 
cations may  invade  the  seat  of  traumatism,  but  must  be  especially  attributed 
to  the  visceral  changes,  rather  than  to  the  gouty  dyscrasia. 

Herpetism. — I  give  this  condition  a  place  here,  although  I  do  not  consider 
it  either  a  distinct  diathesis,  or  a  separate  constitutional  disease.  To  my  mind 
herpetics  are  simply  arthritic  subjects  in  whom  the  predominant  manifesta- 
tions are  on  the  part  of  the  mucous  membrane  and  the  skin.  Herpetism  then 
acts .  upon  injuries  only  after  the  manner  of  rheumatism,  and  especially  of 
gout,  by  producing  at  the  site  of  the  injury  early  or  late  neuralgias,  either 
intermittent,  remittent,  or  continuous ;  and,  in  the  integument  near  the  seat 
of  traumatism,  congestions,  fluxions,  and,  finally,  various  cutaneous  affections, 
among  which  herpes  occupies  the  first  rank,  as  shown  by  the  numerous 
observations  of  traumatic  herpes  which  have  already  been  recorded.  Trau- 
matism is  undoubtedly  a  determining  cause  of  herpetic  manifestations ;  it 
produces  cutaneous  eruptions  at  places  in  which  they  have  never  appeared 
before,  brings  back  with  the  greatest  facility  those  which  have  disappeared, 
and  prolongs  the  existence  of  those  which  are  already  present  in  the  wounded 
region.  Wounds,  properly  speaking,  act  much  more  effectually  in  this  respect 
than  deep-seated  injuries,  whether  or  not  involving  the  great  cavities. 


Cancer. 

Surgical  operations  are  so  frequent  in  cancerous  individuals,  that  it  is  natu- 
ral to  inquire  whether  or  not  cancer  influences  injuries,  and  in  the  event  of 
an  affirmative  answer,  what  changes  it  produces  in  the  reparative  process. 
]Sow  it  must  be  remembered  in  the  first  place  that  cancer,  in  spite  of  what 
has  been  said  on  the  subject,  is  not  a  distinct  constitutional  disease  ;  that  it  is 
included  in  a  much  more  extensive  diathesis,  the  neoplastic  diathesis,  or  the 
tendency  to  produce  neoplasms  spontaneously,  or  under  the  action  of  a  deter- 
mining- cause ;  that  the  neoplastic  diathesis  itself  is  strictly  dependent  upon 
arthritism — which  is  equivalent  to  saying  that  neoplastic  and  cancerous  sub- 
jects are  merely  arthritic  patients  suffering  from  a  special  manifestation  of 
the  constitutional  disease.  v\re  might  therefore  simply  refer  to  the  preceding 
paragraphs  ;  but  a  few  special  remarks  will  perhaps  not  be  useless. 

Cancerous  subjects  belong  to  various  categories.  In  some,  the  disease  is 
latent,  in  a  condition  of  predisposition ;  in  others,  it  already  exists  in  well- 
defined  manifestations.     Some  present  only  a  single  tumor,  others  have  seve- 


314        RECIPROCAL   EFFECTS   OF   CONSTITUTIONAL   CONDITIONS   AND   INJURIES. 

ral  cancerous  deposits  scattered  over  various  parts  of  the  body ;  sometimes 
the  morbid  masses  are  situated  in  the  external  parts,  the  limbs  or  walls  of  the 
splanchnic  cavities,  sometimes  they  occupy  the  viscera  or  deep  parenchymata  ; 
often  they  are  observed  both  externally  and  internally.  Finally,  certain  can- 
cerous patients  present  no  other  lesions  than  the  single  or  multiple  tumors 
with  which  they  are  affected,  while  in  others  we  find  humoral  changes,  or 
more  or  less  serious  disorders  in  organs  which  are  free  from  all  neoplastic 
deposits.  In  certain  predisposed  subjects,  injuries,  and  almost  exclusively 
contusions,  appear  to  invite  the  manifestations  of  the  disease.  Before  com- 
plete recovery,  or  a  longer  or  shorter  time  after  apparent  recovery,  the  centre 
of  traumatism  is  invaded  by  the  neoplasm,  and  the  cancer  appears  at  the  seat 
of  injury. 

Cancerous  patients  who  are  affected  by  single  tumors  situated  in  organs 
not  essential  to  life,  and  whose  viscera  are  healthy,  tolerate  injuries  well ;  the 
reparative  process  pursues  a  normal  course.  The  only  complications  to  be 
feared  are  those  which  are  observed  in  arthritics,  and  which  usually  present 
but  slight  gravity  ;  such  are  traumatic  herpes,  early  secondary  neuralgias,  recur- 
rent attacks  of  rheumatism  or  gouty  paroxysms,  etc.  I  know  of  no  authentic 
example  of  an  open  wound  in  a  cancerous  subject,  in  a  region  exempt  from 
cancer,  which  has  itself  undergone  the  cancerous  metamorphosis.  In  cases  of 
removal  of  tumors,  when  the  ablation  has  been  early  and  free,  the  cicatrices 
are  healthy,  firm,  and  usually  not  liable  to  relapses,  which  readily  occur,  on 
the  other  hand,  in  distant  localities. 

Cancerous  patients  affected  by  multiple  deposits,  and  especially  by  visceral 
tumors,  tolerate  accidental  wounds  and  surgical  operations  very  badly.  A 
large  proportion  succumb  in  consequence  of  even  slight  injuries,  such  as  sim- 
ple fractures,  the  removal  of  small  tumors,  palliative  operations,  tracheotomy, 
formation  of  artificial  anus,  etc.  The  seat  of  injury  may  become  the  site  of 
the  ordinary  complications  of  wounds:  inflammation,  hemorrhage,  ery- 
sipelas, pyaemia,  etc.,  but  more  frequently  still  we  notice  merely  an  almost 
entire  absence  of  the  reparative  process ;  immediate  union,  cleansing  of  the 
wound,  formation  of  the  granular  membrane— all  are  wanting.  At  the  same 
time,  there  are  high  fever  and  profound  adynamia ;  and  death  often  occurs 
very  rapidly  without  its  being  possible  to  ascribe  it  to  any  of  the  recognized 
complications  of  wounds.  The  same  termination  is  usual  in  cachectic  can- 
cerous patients,  in  whom  the  large  viscera  (liver,  kidneys,  heart)  are  affected 
by  fatty  degeneration.  The  complications  which  cause  the  fatal  result  are 
always  better  characterized  in  them,  and  we  find  the  classical  causes  of  opera- 
tive failure,  diffuse  inflammation,  severe  erysipelas,  septicaemia,  pyaemia, 
secondary  hemorrhage,  etc. 

Such  a  case  as  the  following,  which  is  unfortunately  very  common,  cannot 
be  explained  with  our  present  knowledge.  An  operation  is  performed  upon 
a  readily  accessible,  external  tumor,  in  a  cancerous  subject  who  is  apparently 
free  from  all  internal  lesions,  and  who  presents  the  appearances  of  satisfactory 
health.  The  wound  does  not  advance  towards  recovery,  general  symptoms 
appeal-,  death  occurs  with  or  without  local  complications,  and  nothing  is 
found  at  the  autopsy  except  a  few,  small,  cancerous  nodules  scattered  through 
the  lungs,  liver,  or  other  viscera,  and  the  existence  of  which  had  not  been 
suspected.  Though  the  traumatism  may  produce  the  premature  appearance 
of  cancer  by  making  the  injured  part  the  port  of  entry  and  place  of  election, 
it  reacts  even  more  frequently  upon  pre-existing  cancerous  tumors.  Itusually 
accelerates  their  course,  and  causes  an  active  increase  of  the  proliferation. 
This  is  especially  observed  in  cases  of  wounds  of  the  tumor  itself,  such  as  con- 
tusions, exploratory  punctures,  incomplete  operations,  etc.  But  this  irritating 
action  is  exercised  equally  at  a  distance.     Many  times  we  find  that  small, 


SCROFULA.  315 

indolent,  stationary  glands,  which  it  was  not  thought  necessary  to  remove 
when  operating  upon  the  principal  tumor,  rapidly  attain  a  considerable  size, 
soften,  and  ulcerate.  Before  performing  castration,  the  iliac  and  perineal 
regions  may  have  been  examined  with  the  greatest  care,  and  nothing  suspicious 
have  been  discovered ;  but  the  cicatrization  of  the  scrotal  wound  is  scarcely 
effected  before  the  patient  complains  of  lumbar  and  abdominal  pains,  and  pal- 
pation discloses,  deep  in  the  abdomen,  tumors  which  grow  with  extreme 
rapidity. 

Injuries  not  due  to  operations  have  the  same  stimulating  power;  those 
which  are  least  severe,  such  as  simple  fractures  or  contusions  of  the  limbs 
(very  remote,  therefore,  from  visceral  cancers),  may  aggravate  the  latter  to 
such  a  degree  as  to  produce  an  entirely  unexpected  death  within  a  few  days. 
In  some  exceptional  cases,  the  injury,  especially  if  it  is  of  an  operative  nature, 
appears  to  cause  a  temporary  revulsion  and  to  arrest  the  general  progress  of 
the  disease.  This  respite  is  usually  temporary ;  the  wound  has  scarcely  cica- 
trized before  the  cancerous  deposits  assume  or  resume  their  destructive 
course.  Surgical  operations  for  cancer,  when  accompanied  by  profuse  loss  of 
blood,  or  followed  by  profuse  or  prolonged  suppuration,  manifestly  hasten 
the  progress  of  the  cachexia. 


Scrofula. 

Bearing  in  mind  the  morbid  processes  habitually  met  with  in  the  scrofu- 
lous :  inflammation,  not  severe  but  obstinate,  of  slow  course,  and  often  chronic 
from  the  beginning ;  abundant  connective-tissue  proliferation,  readily  set  up 
by  local  irritation,  but  remaining  stationary  and  able  neither  to  disappear 
nor  to  complete  its  organization ;  suppuration  without  inflammatory  reaction 
of  the  surrounding  parts,  often  profuse  and  kept  with  difficulty  within 
bounds ;  indolent,  atonic,  interminable  ulcers,  which  return  on  the  slightest 
occasions,  etc. — we  can  readily  understand  what  modifications  this  constitu- 
tional disease  can  produce  on  the  various  acts  of  the  reparative  process. 

At  first,  this  process  appears  to  progress  as  well  as  could  be  wished ;  the 
traumatic  irritation  and  local  inflammation  are  moderate,  circumscribed, 
without  tendency  to  diffusion,  accompanied  by  scarcely  any  pain  ;  immediate 
union  is  often  attained,  and,  in  cases  of  open  wounds,  the  granular  membrane 
is  rapidly  formed.  After  this  first  effort,  however,  everything  seems  to  have 
come  to  a  stop ;  the  suppuration  becomes  thin  and  serous ;  the  granulations 
grow  pale,  swell  up,  and  soften ;  the  edges  of  the  ulcer,  which  have  ap- 
proached one  another,  separate,  gape  open,  and  grow  thin ;  the  wound  is 
replaced  by  an  ulceration  which,  after  a  short  period,  differs  but  little  from  a 
scrofulous  ulcer  that  has  developed  spontaneously.  In  case  of  interstitial 
injur}r,  the  connective-tissue  proliferation  appears  under  the  form  of  diffuse 
swelling,  fungous  growths  of  the  synovial  membranes,  and  thickening  of  the 
periosteum ;  suppuration  commonly  occurs  in  this  centre  of  induration,  in 
which,  without  doubt,  tubercles  are  sometimes  developed.  These  abscesses 
are  followed  by  inevitable  and  interminable  fistulne,  with  blind  pouches,  sup- 
purating tracts,  and  separations  of  tissue,  whence  stagnation  and  alteration 
of  pus,  almost  inevitably  giving  rise  to  chronic  septicaemia  and  its  conse- 
quences, especially  if  various  parts  of  the  skeleton  are  involved.  Recovery, 
however,  sometimes  occurs  after  a  longer  or  shorter  period,  but  it  is  not  rare 
to  find  a  relapse  of  the  local  complications,  either  on  account  of  fresh  vio- 
lence, even  slight,  affecting  the  parts  formerly  injured  ;  or  under  the  influence 
of  an  intercurrent  disease ;  or  from  the  progress  of  the  scrofula  as  regards 
the  viscera;  or,  finally,  from  the  onset  of  tuberculosis.     There  is  nothing 


316        RECIPROCAL   EFFECTS   OF   CONSTITUTIONAL    CONDITIONS   AND   INJURIES. 

more  common  in  such  cases  than  the  relapse  of  osteitis  or  arthritis,  the  return 
of  abscesses,  reopening  of  fistulae,  etc. 

Scrofula  has  so  great  an  influence  on  the  reparative  process  that  it  im- 
presses its  seal  even  upon  the  cutaneous  cicatrices,  which  remain  indelible 
and  perfectly  characteristic  throughout  life.  On  the  other  hand,  scrofula 
possesses  to  such  a  high  degree  the  vexatious  power  of  indefinitely  prolonging 
traumatic  lesions,  that  it  must  always  be  looked  for,  even  in  individuals  of 
very  healthy  appearance,  whenever  recovery  from  a  wound  is  much  delayed. 

Wounds  inflicted  by  the  surgeon  act  in  precisely  the  same  manner  as  acci- 
dental injuries.  Their  early  phases  are  almost  exempt  from  dangers,  and 
very  rarely  attended  by  wound-complications,  such  as  phlegmon,  gangrene, 
hemorrhage,  pyaemia,  etc.  The  lymphangeitis  and  erysipelas  which  some- 
times start  from  them  are  transient,  and  without  violent  reaction.  Accord- 
ingly, every  one  declares  the  mildness  of  operations  in  the  scrofulous.  This 
opinion  should,  however,  be  combated,  or  at  least  modified.  It  is  true  that 
rapid  death  is  exceptional,  but  complete  and  permanent  recovery  is  not  much 
more  common.  If  we  trace  the  results  of  operations  on  scrofulous  subjects 
with  sufficient  perseverance,  we  will  notice  the  extreme  frequency  of  half- 
successes,  of  incomplete  results,  of  unfinished  cures,  of  relapses  at  an  earlier 
or  later  period ;  so  that  it  is  exceptional  to  find  a  scrofulous  patient  upon 
whom  resection  or  amputation  has  been  performed,  who  is  sound  and  healthy 
ten  years  after  the  operation. 

Traumatism  possesses  to  a  high  degree  the  power  of  awakening,  reawaken- 
ing, and  aggravating  scrofula,  whether  latent  or  already  declared.  In  slight 
cases,  it  causes  from  time  to  time  the  first  manifestation,  in  children  of  tine 
appearance,  of  the  superficial  and  slight  symptoms  of  the  diathesis:  rashes; 
cutaneous  eruptions,  impetiginous  or  otherwise;  subacute  or  indolent  adeno- 
pathies. More  frequently  still  it  stimulates  extinct  or  languishing  centres  of 
disease,  and  restores  to  local  affections  their  original  severity.  Cures  which 
were  believed  to  be  radical,  or,  at  least,  near  at  hand,  are  thus  again  rendered 
doubtful.  Finally,  when  there  are  visceral  lesions  derived  directly  from 
scrofula,  such  as  tubercle  of  the  lungs,  intestines,  mesentery,  or  nervous  cen- 
tres ;  or  which  are  but  consequent  upon  prolonged  suppuration  and  chronic 
septicaemia,  such  as  fatty  and  waxy  degenerations  of  the  liver,  kidneys,  spleen, 
and  intestines;  the  injury  almost  always  proves  fatal  by  the  more  or  less  sud- 
den aggravation  of  affections  which  no  doubt  rendered  life  precarious,  but 
which  nevertheless,  except  for  the  traumatic  shock,  would  have  permitted 
the  patient  to  live  for  some  months,  or  perhaps  even  for  some  years,  longer. 

At  this  stage  of  scrofula,  the  subjects  of  wounds  or  operations  may  un- 
doubtedly succumb  to  local  complications,  but  much  more  frequently  die  of 
marasmus  and  exhaustion — that  is  to  say,  of  phthisis,  albuminuria,  anasarca, 
uncontrollable  diarrhoua  and  inanition — or  of  cerebral  complications. 


Tuberculosis. 

If  pulmonary  tuberculosis  may,  without  hereditary  antecedents  or  evident 
predisposition,  appear  in  the  last  stages  of  almost  all  constitutional  diseases, 
such  as  arthritism,  syphilis,  diabetes,  alcoholism,  etc.,  and  even  of  affections 
which  have  only  involved  the  digestive  functions,  such  as  simple  stricture  or 
carcinoma  of  the  oesophagus  or  rectum,  epithelioma  of  the  tongue,  etc.,  it  is 
none  the  less  true  that,  in  the  immense  majority  of  cases,  tuberculosis  is  an 
appendant  of  scrofula,  or  that, in  other  words,  tuberculous  subjects  are  merely 
scrofulous  siiltjerts  <»f;i  certain  variety. 

The  statements  made  in  the  preceding  paragraph  might  therefore  be  applied 


SCURVY.  317 

to  the  reciprocal  relations  of  tuberculosis  and  traumatism.  It  must  be  re- 
marked, however,  that  as  the  mere  presence  of  tubercles  in  any  organ  what- 
ever indicates  at  once  a  serious  condition  of  the  economy — a  dangerous  form 
of  scrofula — we  must  expect  to  find  the  reparative  process  hindered,  and 
recovery  retarded  or  indefinitely  delayed,  in  wounded  persons  who  are  tuber- 
culous. This  fact  has  been  amply  demonstrated.  The  observations  are 
numerous  in  which  amputations,  in  tuberculous  patients,  have  been  followed 
by  acute  atrophy  of  the  flaps,  by  inflammation,  by  conicity  of  the  stump,  etc. 
This  influence  of  tuberculosis  upon  the  course  and  termination  of  operations 
has  been  known  for  a  long  time;  for  we  find  the  question  discussed  in  old 
books  whether  it  is  wise  or  not  to  amputate  in  phthisical  cases,  or  even  to 
operate  upon  simple  anal  fistula?.  The  advocates  of  abstention  find  no  diffi- 
culty in  making  evident,  in  the  large  majority  of  cases,  not  only  the  dangers 
but  also  the  uselessness  of  surgical  procedures  which  merely  substitute  for  one 
chronic  lesion  another  almost  identical  in  character.  Other  authors,  indeed, 
furnish  facts  which  are  favorable  to  intervention.  The  affirmative  and  nega- 
tive conclusions  of  our  predecessors  are  much  too  general,  and  do  not  reflect 
sufficiently  the  extreme  diversity  of  cases  presented  in  practice.  In  fact,  the 
unfavorable  chances  are  singularly  increased  or  diminished  according  as  the 
tubercles  are  deep  or  superficial ;  abundant,  generalized  and  large,  or  rare, 
discrete  and  small ;  as  they  are  in  course  of  genesis  or  rapid  evolution,  or 
stationary  and  in  course  of  fatty  or  calcareous  degeneration ;  or,  finally,  as  they 
have  more  or  less  disorganized  the  organ  which  they  occupy. 

"Writers,  again,  have  had  too  exclusively  in  view  pulmonary  tuberculosis, 
and  have  left  out  of  sight  tuberculization  of  the  brain,  mesentery,  genital 
organs,  bones,  glands,  etc.  Even  in  respect  to  pulmonary  phthisis  itself,  in 
considering  the  indications  and  contra-indications  for  operation,  the  surgeon 
should  have  regard  to  its  extent,  its  degree,  its' forms,  its  origin,  and  its  causes. 

Finally,  we  must  not  accept  or  reject  indiscriminately  all  operations,  but 
consider  each  one  separately.  Thus,  if  resections  must  be  avoided  in  tuber- 
culous individuals,  we  may  sometimes,  if  only  for  the  purpose  of  prolonging 
life  and  rendering  it  more  comfortable,  perform  amputation,  and,  generally 
speaking,  may  employ  the  whole  series  of  urgent,  and  a  certain  number  of 
palliative  operations. 

Scurvy. 

Essentially  characterized  by  a  change  in  the  blood,  by  friability  of  the 
vascular  walls,  and  by  fatty  degeneration  of  the  tissues  and  especially  of  the 
liver,  scurvy  oft'ers  all  the  conditions  necessary  for  the  production  of  various 
complications  at  the  seat  of  injury.  The  most  important  is  naturally  hemor- 
rhage, so  easily  provoked  by  the  least  violence  exercised  upon  the  vessels  and 
tissues,  that  it  is  almost  always  of  traumatic  origin,  even  when  appearing  to 
be  spontaneous.  The  discharge  of  blood  occurs  at  all  parts:  externally,  into 
the  cavities,  into  the  interstices  of  the  tissues;  and  gives  rise  not  only  to 
hemorrhage  properly  so  called,  but  to  all  the  possible  varieties  of  blood- 
extravasation — extensive  ecehymoses,  suffusions,  infiltrations,  eftusions,  blood- 
tumors,  etc.  To  this  first  cause  of  delay  in  the  local  reparative  process,  must 
be  added  the  more  or  less  complete  absence  of  the  neoplastic  junction;  definitive 
histological  regenerations  are  especially  defective.  Hence  atonic,  obstinate 
ulcerations  of  bad  appearance ;  interminable  suppuration ;  delay  in  the  con- 
solidation of  fractures;  or  production  of  permanent  pseudarthrosis.  The 
callus  already  formed  may  soften  a  longer  or  shorter  time  after  the  fracture; 
cases  are  even  cited  in  which  callus,  that  had  been  solid  for  several  years, 
softened  in  consequence  of  an  attack  of  scurvy. 


318        RECIPROCAL   EFFECTS   OF   CONSTITUTIONAL    CONDITIONS   AND   INJURIES. 

Nothing  justifies  the  belief  that  injury  may  produce  scurvy.  Cases  have 
been  reported  in  which  a  wound,  occurring  in  a  subject  of  healthy  appearance,' 
assumed  a  scorbutic  aspect,  after  which  the  other  symptoms  of  the  disease 
soon  showed  themselves;  but  this  can  be  explained  as  well  by  saying  that, 
at  the  period  of  injury,  the  scurvy  did  not  exist,  and  that  it  was  developed 
as  an  intercurrent  disease ;  or  that  it  was  yet  latent  and  ill-defined,  and  that, 
after  the  maimer  of  other  diatheses,  it  first  showed  itself  at  the  seat  of  injury 
as  at  the  place  of  least  resistance.  In  confirmed  scorbutics,  wounds  sensibly 
aggravate  the  general  condition,  and  contribute  to  the  decay  of  the  .organism, 
by  primary  or  secondary  loss  of  blood,  and  by  prolonged  suppuration. 


Leucocttilemia. 

The  number  of  cases  hitherto  collected  is  still  very  small,  but  is  already 
sufficient  to  prove  the  disastrous  influence  exercised  by  leucocythsemia  upon 
accidental  or  operative  wounds.  The  most  frequently  observed  complication, 
at  the  site  of  injury,  is  rapid  or  slow  hemorrhage,  which  is  almost  always 
uncontrollable,  and  almost  inevitably  leads  to  death.  This  hemorrhage  does 
not  appear  after  capital  operations  only,  but  follows  also  insignificant  wounds, 
such  as  biting  the  tongue,  paracentesis  abdominis,  the  application  of  leeches, 
lancing  the  gums,  etc.  The  few  patients  operated  upon  who  do  not  perish 
from  loss  of  blood,  die  of  phlegmon,  phlebitis,  pyaemia,  or  peritonitis,  espe- 
cially after  splenotomy — an  operation,  which  has  now  been  practised  at  least 
fifteen  times  upon  leucocythaeihic  patients,  and  which  has,  under  these  cir- 
cumstances, always  been  followed  by  death. 

Certain  more  or  less  conclusive  observations  lead  to  the  belief  that  injuries 
may  by  themselves  engender  leucocythaemia.  Splenic  contusions  have  been 
cited  in  the  first  place — cases  in  which  the  hypothesis  is  acceptable;  then  a 
fracture  of  the  thigh,  a  sprain,  the  extirpation  of  tonsils  in  a  state  of  chronic 
inflammation;  in  a  word,  injuries  not  primarily  affecting  the  spleen.  With 
regard  to  the  latter  cases,  at  least,  it  appears  more  probable  that  the  leuco- 
cythaemia  pre-existed,  but  in  a  mild  and  latent  condition,  and  that  the  injury 
aggravated  and  rendered  it  evident,  This  stimulating  action  is  moreover 
demonstrated  by  a  case  in  wmich  a  wound  of  the  leg  gave  rise  to  peritonitis 
starting  from  the  diseased  spleen.  Injuries  sometimes  shake  the  organism  of 
leucocythaemic  patients  to  such  a  degree  that  they  immediately  sink  into  a 
rapidly  fatal  collapse. 

HAEMOPHILIA. 

It  would  certainly  be  surprising  not  to  find  in  the  list  of  constitutional 
conditions  bearing  a  relation  to  traumatism,  this  condition,  peculiar  to  cer- 
tain individuals,  in  whom  the  blood  tends  to  escape  by  every  channel,  and  in 
whom  there  is  no  tendency  to  the  production  of  spontaneous  haemostasia. 

However,  before  recalling  what  is  contained  in  the  books,  I  experience  a 
certain  embarrassment,  because,  in  my  tolerably  large  experience,  I  have  never 
seen  a  case  of  haemophilia;  because  the  subjects  in  whom  I  have  myself 
observed  this  tendency  to  bleed,  and  this  difficulty  of  haemostasis,  have  been 
merely  patients  suffering  from  hepatic  disease,  malaria,  diabetes,  scurvy, 
leucocytnaemia,  etc.;  because  among  the  published  observations  the  majority 
are  very  incomplete  from  a  clinical  point  of  view  as  well  as  in  reference  to 
pathological  anatomy;  because,  moreover,  these  observations  become  more 
and  moire  rare  in  proportion  as  we  become  better  acquainted  with  diathetic 
hemorrhages;  because,  to   express   my  meaning   in  one  word,  1  am  in   no 


SYPHILIS.  319 

decree  convinced  that  there  is  such  a  special  condition,  deserving  a  special 
place  in  nosology  and  a  special  name,  and  because,  if  haemophilia  really  has 
an  existence,  I  shall  wait  for  it  to  be  a  little  better  demonstrated. 


Syphilis. 

During  its  always  prolonged,  if  not  indefinite,  duration,  syphilis  may  show 
itself  or  disappear  several  times,  or  be,  in  other  words,  alternately  manifest 
or  latent.  The  first  condition  is  common  in  the  beginning  of  the  disease, 
during  the  first  two  or  three  years  or  even  later,  when  treatment  has  been 
wanting  or  imperfect.  In  the  opposite  condition,  the  syphilitic  may  enjoy 
excellent  health  for  a  long  term  of  years  without  any  apparent  symptoms. 
Syphilis  may,  therefore,  be  recent  or  old,  evident  or  masked,  when  the  injury 
occurs.  In  the  immense  majority  of  cases,  the  wound  progresses  naturally 
without  appearing  to  be  influenced  by  the  constitutional  disease,  but  the 
reverse  sometimes  occurs,  so  that  the  work  of  repair  is  more  or  less  interfered 
with.  It  will  not  be  useless,, in  order  that  the  modifications  undergone  may 
be  appreciated,  to  recall  the  circumstance  that  the  pathological  processes  of 
syphilis  strongly  resemble  those  of  scrofula.  In  fact,  we  find  here  the  same 
proliferation  and  connective-tissue  new  formation- — abundant,  but  useless, 
superfluous,  even  hurtful,  as  the  new  tissue  strangles  the  old  and  finally 
replaces  it  by  fibrous  or  cicatricial  products.  "We  also  observe  the  tendency 
to  obstinate  ulceration  and  indefinitely  delayed  repair.  It  is  to  be  remarked 
that  the  two  constitutional  diseases  attack  the  same  systems :  the  external  or 
internal  tegument,  osseous  system,  lymphatic  system,  etc. ;  and  that,  finally, 
in  their  last  stages  or  their  grave  forms,  they  generate  products  which  are 
to  a  certain  extent  special  and  closely  related,  the  tubercle  on  the  one  hand 
and  the  gumma  on  the  other.  We  should,  however,  remember  to  the  credit 
of  syphilis,  the  much  more  pronounced  tendency  of  its  local  manifestations 
to  disappear  spontaneously,  or  to  yield  to  treatment,  though  ready  to  return 
on  the  slightest  occasion,  under  the  same  form,  or  even  under  a  different 
aspect. 

These  facts  enable  us  to  understand  what  sometimes  occurs  at  the  seat  of 
injury:  in  cases  of  fracture — delay  or  complete  absence  of  consolidation,  the 
repair  being  restricted  to  the  formation  of  fibrous  callus  which  does  not 
undergo  ossification;  in  cases  of  simple  contusion  of  bone — osteitis,  periostitis, 
exostosis,  periostosis,  suppurating  gummata,  subperiosteal  abscesses,  osseous 
denudations,  necroses  which  are  interminable  on  account  of  the  non-forma- 
tion of  natural  sequestra.  A  contusion,  even  if  confined  to  the  soft  parts, 
sometimes  gives  rise  to  indolent  phlegmons  which  pursue  a  chronic  course, 
with  scarcely  any  suppuration,  and  which  leave  behind  them  either  fistulas,  or 
indurations,  or  ulcerating  wounds.  If  the  contusion  be  severe  and  circum- 
scribed, the  skin  may  become  gangrenous,  and,  upon  the  separation  of  the 
eschar,  Ave  find  a  wound  which  "possesses  all  the  characteristics  of  an  ulcer- 
ating syphilide  or  gumma. 

t  Wounds  made  by  cutting  instruments  may  also  suffer  the  influence  of  the 
diathesis,  although  this  is  of  rarer  occurrence.  A  failure  of  immediate  union 
has  m  the  first  place  been  noticed,  and,  as  a  consequence,  an  unsuccessful 
result  of  autoplastics  ;  then  again  there  may  be  early  or  lafe ■■modifications  in 
the  course  of  the  cicatrization.  Sometimes  the  wound  assumes  the  appear- 
ance of  an  ulcerating  or  perhaps  even  of  a  serpiginous  syphirme;  sometimes  it 
ulcerates  without  assuming  a  specific  appearance,  and  does  not  heal ;  finally, 
it  may  retain  the  appearances  of  an  ordinary  wound,  but  persist  indefinitely, 
or  it  may  cicatrize  after  a  certain  time  only  to  break  open  again  in  a  short 


320        RECIPROCAL   EFFECTS   OF   CONSTITUTIONAL   CONDITIONS   AND   INJURIES. 

period.  As  for  the  rest,  there  is  complete  uncertainty  as  to  the  period  at 
which  the  diathesis  will  disturb  the  curative  process.  This  disturbance,  in 
fact,  may  occur  immediately  after  the  injury,  a  few  days  afterwards,  or  even 
some  weeks  or  months  subsequently.  It  is  common  to  find  that  the  wound 
at  first  follows  a  normal  course,  then  remains  stationary,  and  finally  assumes 
a  syphilitic  aspect. 

Syphilis  seldom  attacks  wounds  during  the  first  months  of  its  existence ;  it 
affects  them  more  readily  when  it  is  of  older  date ;  when  it  has,  as  it  were, 
impregnated  the  economy  more  intimately.  However,  we  can  formulate  no 
distinct  rule  in  this  respect,  since,  in  a  very  large  number  of  cases,  wounds 
have  been  found  to  undergo  the  specific  metamorphosis  in  patients  who  have 
been  free  from  all  syphilitic  manifestations  for  ten,  fifteen,  or  twenty  years, 
or  even  longer.  The  chances  of  the  occurrence  of  this  metamorphosis  appear 
moreover  to  be  the  greatest  when  the  injury  affects  tissues  already  changed, 
even  though  from  other  than  syphilitic  causes.  Furthermore,  other  examples 
equally  prove  the  predilection  with  which  syphilis  takes  hold  of  places  of 
least  resistance  which  have  become  such  a  longer  or  shorter  period  before  its 
invasion.  Thus  it  has  more  than  once  been  found  to  select  as  the  site  of  its 
local  manifestations  some  old  seat  of  traumatism  which  had  become  entirely 
extinct,  and  the  cure  of  which  would  otherwise  have  remained  permanent. 

If  the  quality  of  the  wounded  tissues  establishes  an  evident  predisposition  ; 
if  the  quality  of  the  poison  is  also  probably  a  factor  in  the  determination  of 
the  mild,  moderate,  or  grave  forms  of  the  disease ;  surely  we  are  permitted  to 
believe  a  priori  that  the  character  of  the  constitution,  that  is  to  say  the  ante- 
rior constitutional  condition  of  the  wounded  syphilitic,  will  react  upon  the 
injury,  aid  in  modifying  its  course  and  termination,  and  recall,  in  certain  cases, 
the  diathetic  manifestation.  But  we  must  remember  that,  however  probable 
this  may  be,  it  has  not  been  demonstrated.  In  syphilitics  who  are  in  a  con- 
dition of  cachexia,  or  who  suffer  from  grave  visceral  lesions  of  the  liver,  lungs, 
kidneys,  or  nerve-centres,  the  reparative  process  goes  on  no  better  than  in 
other  subjects  whose  health  is  ruined,  and  may  be  complicated  by  disorders 
common  to  all  cachexias,  such  as  gangrene,  hemorrhage,  difFuse  inflammations, 
etc.  In  these  disorders,  the  part  played  by  syphilis,  properly  speaking,  is 
relatively  small,  or  at  least  very  indirect. 

Let  us  now  speak  of  the  reciprocal  action.  It  is  absent  much  more  fre- 
quently than  it  is  present ;  we  will  here  consider  only  those  cases  in  which  it 
is  manifest. 

Of  course,  an  injury  cannot  produce  syphilis;  but  it  may  introduce  it  into 
the  economy,  attract  it  to  the  wounded  point,  aggravate  it,  and  make  it  pass 
from  the  latent  to  the  active  stage.  In  the  immense  majority  of  cases,  the 
infection  is  produced  through  the  medium  of  an  injury,  though  very  slight 
and  almost  microscopical,  We  have  already  said  that  old  wounds  are  some- 
times attacked  by  syphilitic  complications  in  preference  to  healthy  tissues,  but 
the  most  common  cases  are  those  in  which  the  injury  affects  syphilitics  who 
have  been  infected  for  a  longer  or  shorter  period.  At  this  point  two 
facts  appear:  either  evident  syphilitic  manifestations  are  present,  or  the  dis- 
ease is  entirely  latent.  In  the  first  event,  the  lesions  receive  a  more  or  less 
active  impetus,  and  become  more  or  less  grave;  in  the  second,  they  appear 
to  originate  full-blown,  and  to  attack  organs  or  regions  which  had  previously 
escaped.  They  occur  under  the  form  of  secondary  or  tertiary  complications, 
according  to  the  stage  to  which  the  intoxication  has  advanced  in  the 
wounded  subject.  The  tertiary  stage  predominates  when  the  syphilis  dates 
back  some  years,  even  when  it  has  never  produced  any  secondary  symptoms. 
These  complications  appear  at  the  point  of  injury  in  the  centre  of  trauma- 
tism, or  in  its  neighborhood:  they  arc  local  manifestations  excited  by  the 


MALARIA.  321 

trauma  ;  or  at  a  distance,  but  in  a  single  organ  or  in  a  circumscribed  region ; 
or  finally  in  several  parts  of  the  economy  at  once,  as  it*  there  was  a  recent 
infection  which  had  become  generalized. 

The  diathetic  manifestations  thus  forcibly  provoked  by  the  stimulating 
action  of  an  injury,  are  a  valuable  means  of  diagnosis,  revealing  the  exist- 
ence of  a  syphilitic  taint  of  which  the  patients  themselves  are  ignorant,  or 
which  they  believe  to  have  been  long  since  extinct.  They  usually  present  no 
exceptional  gravity,  and  yield  quite  readily  to  well  directed  treatment. 

Malaria. 

Of  all  constitutional  conditions,  malaria  is  perhaps  that  which  reacts  most 
upon  the  centre  of  traumatism,  and  which  reciprocally  experiences  most  fre- 
quently the  counter-stroke  of  the  injury.  Accordingly,  in  countries  in  which 
malarial  poisoning  is  endemic,  it  is  expected  that  the  reparative  process  should 
be  constantly  disturbed  by  various  complications,  while  wounds,  on  the  other 
hand,  excite  or  renew  attacks  of  intermittent  fever.  In  our  temperate  climate, 
and  in  large  cities,  these  facts,  though  of  rarer  occurrence,  are  nevertheless 
met  with.  Malaria  may  give  rise,  at  the  site  of  injury,  to  various  complica- 
tions, such  as  hemorrhage,  neuralgia,  erysipelas,  spasms,  and  even  tetanus ;  com- 
plications which  assume  an  intermittent  type,  and  which  yield  to  the  employ- 
ment of  sulphate  of  quinia.  But  the  influence  of  the  poison  is  not  always 
shown  by  periodical  disturbances.  We  find  in  fact  that  certain  wounds 
assume  a  bad  appearance,  or  at  least  remain  stationary,  until,  the  cause  being 
suspected,  preparations  of  quinine,  which  act  like  a  charm,  are  adminis- 
tered. It  is  especially  in  cases  of  malarial  cachexia  that  are  observed  that 
slowness  and  insufficiency  of  repair  which  terminate  in  serious  diffuse  in- 
flammations, or  even  in  gangrene,  and  which  are  not  always  subdued  by  anti- 
periodic  remedies. 

The  injury  may  occur  under  the  following  various  circumstances:  (1)  In  a 
patient  actually  affected  by  intermittent  fever.  In  this  case  the  wound, 
especially  if  it  is  followed  by  hemorrhage,  rapidly  and  markedly  aggra- 
vates the  disease.  (2)  In  a  patient  who  has  previously  been  subject  to  inter- 
mittent fever,  but  who  appears  to  have  entirely  recovered.  The  injury,  even 
when  of  slight  importance,  such  as  a  contusion,  subcutaneous  fracture,  punc- 
ture, slight  wound  or  operation,  and  although  the  recovery  from  the  fever  may 
have  occurred  many  years  previously  (five,  ten,  or  fifteen  years,  and  even 
more),  reawakens  the  latter  or  itself  experiences  its  influence,  which  shows 
itself  under  the  form  of  local  intermittent  complications.  It  may  even  hap- 
pen that  these  complications  (hemorrhage,  neuralgia,  spasm),  instead  of  choos- 
ing a  site  at  the  wounded  point,  appear  in  a  totally  different  region  of  the 
body,  not  affected  by  the  traumatism,  and  thus  clearly  indicate  the  return  of 
the  disease.  (3)  In  a  patient  who  has  never  had  intermittent  fever,  and  who 
lives  in  a  healthy  country,  but  who  formerly  resided  in  a  malarial  district. 
The  wound,  in  such  cases,  may  apparently  give  rise  to  intermittent  fever  or 
to  intermittent  complications.  It  is  very  clear  that  the  injury,  not  being  able 
of  itself  to  produce  a  true  intoxication,  has  merely  provoked  the  explosion  of 
a  hitherto  latent  disease,  and  forced  it  to  reveal  itself  by  pathognomonic 
manifestations.  These  latter  cases  are  not  very  rare,  and  are  especially 
ol  (served  in  large  cities  and  in  the  healthiest  regions.  They  must  not  be 
confounded  with  other  cases  in  which  intermittence  is  also  evident,  but  which 
bear  no  relation  to  malaria.  It  appears  astonishing  at  first  sight  that  a  dis- 
ease, which  is  generally  so  well  characterized  and  so  readily  recognized,  can 
remain  so  long  and  so  completely  latent.  "We  will  be  less  surprised  if  we 
VOL.  i.— 21 


322        RECIPROCAL    EFFECTS    OF    CONSTITUTIONAL    CONDITIONS    AND    INJURIES. 

recall  the  fact  that  the  fever  is  not  the  sole  indication  of  the  malarial  poison- 
ing, and  that,  without  having  had  a  single  attack  in  an  infected  district,  the 
system  may  nevertheless  be  impregnated  by  the  disease.  Malarial  anaemia 
and  concealed  neuralgias  characterize  malaria  almost  as  well  as  tertian  or 
quartan  fever. 

Moreover,  care  must  be  taken,  in  whatever  district  it  may  be,  not  to  con- 
fuse the  fever  which  has  been  aroused  with  those  quite  numerous  cases  in 
which  periodicity  is  present  without  the  slightest  relation  to  malarial  infec- 
tion. I  will  mention,  among  others,  those  curious  cases  of  wmmds  of  the 
spleen  which  give  rise  to  traumatic  splenitis,  accompanied  by  distinctly  peri- 
odical febrile  seizures,  and  readily  amenable  to  treatment  by  quinine;  as  also 
those  equally  periodical  seizures,  which  are  equally  curable  by  sulphate  of 
quinia,  and  which  are  due  to  affections  of  the  urinary  passages,  in  men  suffer- 
ing from  disease  of  the  kidneys. 


Alcoholism. 

Acute  and  chronic  intoxication  must  be  studied  separately.  Simple  drunk- 
enness, modifies  certain  primary  phenomena  of  wounds,  viz.,  pain  and  muscu- 
lar contraction ;  it  may  obscure  the  diagnosis,  especially  in  traumatic  lesions 
of  the  head  and  spine ;  it  sometimes  renders  difficult  the  treatment  of  certain 
surgical  affections,  by  interfering  with  the  application  of  instruments  and 
dressings;  at  other  times,  on  the  contrary,  by  causing  muscular  relaxation,  it 
facilitates  the  reduction  of  luxations.  Casual  drunkenness  has  generally  no 
marked  action  upon  the  course  of  a  wound,  and  does  not  prevent  the  perform- 
ance of  certain  urgent  operations,  such  as  tracheotomy,  catheterization,  the 
arrest  of  hemorrhage,  etc.  It  constitutes,  however,  a  contra-indication  to  the 
employment  of  anaesthetics.  Resort  was  had  to  it,  in  former  times,  as  a 
therapeutic  agent  in  various  surgical  affections,  such  as  luxations,  tetanus, 
septicaemia,  etc. ;  but  the  employment  of  other  anaesthetics  is  far  preferable  if 
we  wish  to  obtain  muscular  relaxation ;  and  if  we  desire  to  use  alcohol  as  an 
antiseptic,  it  is  useless  to  push  it  so  far  as  to  cause  intoxication.  Traumatism 
sometimes  modifies  the  phenomena  of  drunkenness,  the  effects  of  which  it 
increases  or  diminishes;  now  sobering  one  individual,  and  again  rendering 
another  even  more  violent. 

Chronic  alcoholism  is  a  predisposing  cause  of  injury.  The  drunkard  has 
hallucinations  and  a  tendency  to  suicide;  he  readily  loses  the  sense  of  self- 
preservation,  and  commits,  even  wThen  fasting,  a  host  of  extravagances.  The 
keenness  of  his  senses  is  diminished,  as  well  as  the  promptness  and  precision 
of  his  protective  and  defensive  acts.  If  hard  drinking  and  drunkenness 
should  disappear,  we  could  dispense  with  one-third  of  the  beds  in  our  surgi- 
cal wards.  Chronic  alcoholism  profoundly  modities  the  reparative  process, 
is  singularly  prejudicial  to  the  healing  of  accidental  or  operative  wounds,  and 
greatly  aggravates  the  prognosis  of  traumatism  in  general.  In  fact,  every 
wound,  although  of  itself  of  slight  importance  (contusions,  subcutaneous  frac- 
tures, punctures,  excoriations),  may  be  followed  by  death  in  drunkards.  This 
termination  is  often  due  to  complications  starting  from  the  wound,  such  as 
lymphangeitis,  erysipelas,  hemorrhage,  diffuse  phlegmon,  gangrenous  inflam- 
mation, or  sphacelus,  the  whole  accompanied  or  followed  by  grave  traumatic 
fever  or  pyaemia,  and  the  entire  train  of  the  adynamic  and  ataxic  symptoms 
of  severe  blood-poisoning.  These  complications  are  the  more  alarming  as  the 
chenfical  composition  and  structure  of  the  humors  and  tissues  have  been  more 
profoundly  modified  by  the  alcohol, and  as  these  disorders  affect  organs  more 
essential  to  life,  such  as  the  brain,  or  those   more  directly  concerned  with 


ALCOHOLISM.  323 

nutrition,  such  as  the  lungs,  liver,  and  kidneys.  They  do  not  always  cause 
swift  death,  and  may  even  disappear  quite  rapidly;  then  the  curative  process, 
which  has  been  temporarily  suspended,  resumes  its  course  with  more  or  less 
activity  and  rapidity ;  but  it  may  also  be  subject  to  fresh  periods  of  arrest, 
languish  for  an  indefinite  period,  and  even  retrograde.  We  then  observe  pro- 
fuse suppuration,  the  absence  of  secondary  union,  and  the  formation  of  atonic 
wounds  and  callous  ulcers.  After  various  alternations,  recovery  may  finally 
occur,  but  it  is  at  least  as  common  to  find  fresh  complications  supervene, 
rendering  the  local  lesions  manifestly  incurable,  and  leaving  no  other  alterna- 
tive than  death  from  cachexia,  or  surgical  interference  of  the  most  dangerous 
kind. 

The  danger  of  wounds  in  drunkards  is  none  the  less  serious  when  it  comes 
reciprocally  from  the  action  of  the  traumatism  on  alcoholism.  It  is  not  rare 
to  find  that  a  wound  recalls,  with  more  or  less  violence,  the  manifestations  of 
alcoholism  which  is  latent,  or  which  has  been  long  believed  to  have  disappeared. 
In  the  first  rank  stands  Delirium  Tremens.  This  serious  complication  may 
arise  suddenly,  a  few  hours  after  the  injury,  and  by  a  true  refiex  action  upon 
the  previously  affected  cerebral  organ;  or  it  may  appear  at  later  periods, 
when  the  septic  poison  originating  in  the  wound  and  produced  by  the  local 
complications  has  more  or  less  poisoned  the  blood.  Be  that  as  it  may,  this 
delirium  tremens  of  traumatic  origin  is  of  considerable  gravity,  and  often 
resists  all  the  measures  which  are  directed  against  it.  Delirium  is  not  the 
only  neuropathy  which  injury  may  produce  or  awaken  in  the  victims  of 
alcohol ;  there  must  also  be  noted,  epileptiform  convulsions,  tetanic  spasms, 
hyperesthesia  and  anaesthesia,  hallucinations,  and  other  psychical  disturb- 
ances. 

The  reaction  of  the  traumatism  upon  the  other  viscera  affected  prior  to  the 
wound,  though  less  sudden  and  violent,  is  none  the  less  very  threatening. 
On  the  part  of  the  digestive  tract  appear  vomiting,  anorexia — sometimes 
complete — and  the  malnutrition  which  results  therefrom.  When  the  liver  is 
cirrhotic  or  fatty,  secondary  hemorrhages  are  greatly  to  be  dreaded,  as  are 
also  albuminuria  and  uremic  phenomena  when  the  kidneys  are  affected. 
In  case  of  fatty  degeneration  of  the  heart,  we  must  have  in  our  minds  the 
liability  to  residual  Overdistension  (asystolie),  which  has  been  already  several 
times  observed  in  drunkards,  and  which  explains  the  sudden  or  very  rapid 
death  sometimes  observed  in  their  cases.  In  other  words,  when  we  remem- 
ber that  alcohol  produces  three  principal  lesions,  to  wit,  fatty  degeneration 
and  cirrhosis  in  the  parenchymatous  organs,  and  atheroma  in  the  vessels;  and 
that  in  inveterate  drinkers  all  the  tissues  and  organs  are  more  or  less  deterio- 
rated, and  all  the  functions  more  or  less  compromised,  we  may  understand 
that  death  may  occur  in  several  ways,  and,  in  some  manner,  through  all  the 
more  important  organs. 

To  certain  lesions,  however,  correspond  certain  disorders  which  destroy  life 
by  a  constant  mechanism. 

In  crushes  of  the  limbs  and  compound  fractures  for  instance,  death  occurs 
from  acute  septicemia.  The  centre  of  traumatism  rapidly  becomes  the  site 
ot  an  intense  phlegmonous  inflammation,  which  extends  step  by  step,  and  soon 
involves  the  entire  limb;  the  connective  tissue  is  infiltrated  with  gas  and 
putrid  fluids;  sphacelus  at  once  attacks  the  contused  parts,  and  cadaveric 
decomposition  appears  to  commence  before  death.  Surgical  interference  is 
almost  useless;  amputation  and  resection  are  unavailing.  Antiseptic  dress- 
ings applied  immediately  after  the  accident  have  saved  some  wounded  alco- 
holics, but  still  permit  the  death  of  the  larger  number. 


324        RECIPROCAL   EFFECTS   OF   CONSTITUTIONAL    CONDITIONS   AND   INJURIES. 


Morphinism. 

In  regard  to  morphinism,  we  possess  but  few  records,  and  those  unaccom- 
panied with  many  details.  Opium  administered  continuously,  and  in  moderate 
doses,  is  rather  favorable  to  the  cure  of  wounds,  and  more  than  one  surgeon 
has  extolled  its  use  in  severe  injuries.  But,  as  in  the  case  of  alcohol,  there 
is  a  great  difference  between  use  and  abuse,  and  in  the  same  way  that  there 
is  an  acute  and  a  chronic  alcoholism,  there  are  also  acute  and  chronic  forms 
of  poisoning  by  opium.  The  latter  variety,  which  was  formerly  known  only 
in  the  Orient,  has  in  its  turn  invaded  the  Western  world  since  the  extensive 
employment  of  narcotics  by  subcutaneous  injection.  Chronic  morphinism 
is  the  only  variety  with  the  effects  of  which  upon  the  course  of  injuries  we 
are  somewhat  acquainted.  Thus  at  the  locality  of  hypodermic  injections 
have  been  noticed  phlegmons,  abscesses,  and  spots  of  gangrene ;  at  the  site  of 
operative  wounds,  erysipelas,  bronzed  inflammation,  orange-colored  suppura- 
tion ;  in  a  word,  complications  which  are  very  analogous  to  those  observed 
in  alcoholics,  and  in  diabetic  and  albuminuric  patients. 

While  waiting  for  carefully  made  autopsies  to  show  the  nature  of  the 
histological  lesions  produced  by  slow  morphia  poisoning,  experimentation 
and  clinical  study  enable  us  to  compare  morphinism  to  the  constitutional 
conditions  described  above.  In  fact,  by  injecting  toxic  doses  of  morphia  in 
animals,  we  produce  albuminuria,  glycosuria,  and  ocular  lesions  which  are 
comparable  to  those  caused  by  these  two  diseases;  and  furthermore,  examina- 
tion after  death  reveals  intense  congestion  of  the  nerve  centres,  and  of  the 
liver  and  kidneys.  Moreover,  this  albuminuria  and  this  glycosuria  have 
been  already  noticed  in  morphiomaniacs.  Charcot,  for  his  part,  has  observed 
the  development  of  furious  delirium  in  morphiomaniacs,  and  in  a  case  of 
pneumonia  this  latter  affection  terminated  in  gangrene.  It  is  easy  to  under- 
stand that  opium-eaters  should  present  at  the  seat  of  injury  complications 
with  which  they  might  be  affected  at  any  point  whatever,  without  its  direct 
implication,  and  simply  in  consequence  of  the  poisoning  itself  or  of  the 
visceral  lesions  which  it  produces. 

We  know  nothing  of  the  reciprocal  influence  which  traumatism  may 
exercise  upon  morphinism.  We  will  merely  mention  as  a  fact  which  is 
interesting  to  surgeons,  that  the  use  of  chloroform  demands  special  precau- 
tions in  individuals  who  habitually  make  excessive  use  of  morphia.  Though 
relaxation  is  usually  produced  in  them  with  readiness,  the  narcosis  may  be 
prolonged  for  an  extremely  long  time,  and  may  be  accompanied  by  a  depres- 
sion of  temperature  which,  in  some  cases,  has  awakened  well-founded  a] •pre- 
hensions. 

As  a  sequel  to  these  remarks  on  morphinism,  we  should  no  doubt  speak  of 
the  more  or  less  analogous  intoxications  caused  by  belladonna,  tobacco, 
haschish,  and  some  other  narcotic  substances.  But,  unfortunately,  we  must 
for  the  present,  in  absence  of  the  necessary  information,  leave  blank  a  space 
which  the  future  will  certainly  fill. 


Saturnism  or  Lead-Poisoning. 

Animal  and  vegetable  matters  do  not  alone  possess  the  baleful  privilege  of 
poisoning  the  organism,  and  of  giving  rise,  like  general  diseases,  to  permanent 
constitutional  conditions;  the  metalloids  and  metals  also  have  the  same 
property.  We  are  in  the  possession  of  valuable  knowledge  with  regard  to 
this  class  of  poisonings,  several  of  which  have  even  received  special   names. 


HEPATISM — NEPHRISM — CARDISM.  325 

Thus  we  speak  of  iodism,  mcrcurialism,  and  saturnism,  and  we  shall  soon 
speak  of  phosphorism,  arsenicism,  etc.  The  list  will  become  very  markedly 
extended  as  soon  as  shall  be  included  in  the  pathology  of  artisans  all  the 
special  morbid  conditions  produced  by  the  constant  employment  of  this  or 
that  toxic  substance. 

These  poisons  naturally  bring  into  the  chemical  composition  of  our  fluids, 
and  into  the  histological  constitution  of  our  tissues  and  organs,  modifications, 
some  of  which  have  already  been  well  described.  Naturally,  also,  these  dys- 
erasise  and  these  peripheral  or  visceral  lesions,  modify  the  reparative  process 
in  cases  of  wounds.  Unfortunately,  we  can  here  only  form  conjectures  and 
hypotheses,  surgeons  not  having  hitherto  concerned  themselves  with  the 
manner  in  which  injuries  act  in  individuals  poisoned  by  phosphorus,  arsenic, 
mercury,  etc. 

More  anxious  to  mark  a  place  for  these  investigations,  than  capable  of 
illustrating  the  subject  by  my  personal  experience,  I  have  made  a  short 
section  on  saturnism,  as  I  have  already  collected  some  observations  on 
wounds  occurring  in  individuals  suffering  from  lead-poisoning.  In  one,  a 
contusion  gave  rise  to  a  renewed  attack  of  lead-colic;  in  another,  an 
insignificant  wound  of  the  great  toe  was  followed  by  lymphangeitis  of  rapid 
course;  in  a  third,  the  onset  of  saturnism  caused  the  reopening  of  a  focus  of 
suppuration  which  had  been  closed  for  ten  years.  Two  amputations,  one  of 
the  leg,  the  other  of  the  arm,  performed  in  patients  of  this  class  were  not 
followed  by  any  complications.  No  conclusions  can  be  reached  until  we  are 
in  possession  of  a  larger  number  of  facts. 


Hepatism  ;  Nephrism  ;  Cardism. 

"We  have  already  laid  down  the  principle  that  every  old  or  serious  lesion 
of  an  important  viscus,  whatever  may  be  its  origin  and  causes,  produces,  after 
a  longer  or  shorter  interval,  a  change,  first  in  the  chemical  composition  of  the 
fluids,  and  then  in  the  anatomical  constitution  of  the  solids ;  creating,  in  a 
word,  a  general  morbid  condition,  imperfectly  defined  perhaps,  but  as  dan- 
gerous to  life  as  a  well-determined  disease.  Such  changes  inevitably  occur  in 
patients  suffering  from  affections  of  the  liver,  kidney's,  heart,  spleen,  lungs, 
intestines,  and  doubtless  also  the  brain.  It  is  true  that,  in  many  of  these 
individuals,  the  lesions  of  the  liver,  kidney,  heart,  etc.,  are  neither  primary 
nor  isolated,  and  that  they  form  part,  on  the  contrary,  of  a  pre-existing  mor- 
bid entity — so  that,  for  example,  a  patient  suffering  from  hepatic  disease  is 
an  alcoholic,  one  suffering  from  kidney  disease  is  gouty,  and  one  from  heart 
disease  rheumatic.  Nevertheless,  while  taking  the  general  disease  into  con- 
sideration, great  interest  attaches  to  an  examination  of  the  peculiar  influence 
exerted  upon  it  by  the  marked  alteration  of  this  or  that  viscus.  In  fact, 
constitutional  diseases  do  not  always  implicate  the  same  organs,  and  do  not 
always  affect  them  with  the  same  intensity ;  not  all  rheumatics  suffer  from 
cardiac  disease ;  not  all  alcoholics  have  a  diseased  liver ;  and  a  patient  may 
be  gouty  though  the  kidneys  are  in  good  condition.  Clinically  there  is  room 
for  investigating  (1)  what  differences  would  be  presented  by  three  rheumatic 
patients,  one  of  whom  had  a  mitral  lesion,  a  second  biliary  lithiasis,  and  the 
third  albuminuria  ;  and  (2)  the  differences  noticeable  in  three  cases  of  hepatic 
disease,  in  which  the  causes  of  the  lesions  were  alcoholism,  syphilis,  or  pro- 
longed suppuration  of  bone. 

In  the  field  of  surgery  these  researches  are  no  less  important,  experience 
having  shown  that  injured  persons  are  exposed  to  serious  complications 
whenever  one  of  the  important  viscera  has  been  previously  affected,  and  that 


326        RECIPROCAL   EFFECTS   OF   CONSTITUTIONAL    CONDITIONS   AND   INJURIES. 

there  are  intimate  relations  between  the  nature  of  the  complications  and  the 
lesion  of  this  or  that  organ.  1  have  thought  it  well  to  reproduce  hero  some 
of  the  information  which  we  possess  on  this  subject.  It  is  necessary,  how- 
ever, to  remark  that  though  the  framework  may  be  prepared,  it  cannot  at  this 
time  be  filled  up.  We  possess  somewhat  precise  information  only  in  regard 
to  those  conditions  which  are  produced  by  hepatic,  by  renal,  and  by  cardiac 
affections ;  in  the  future,  the  series  will  undoubtedly  be  made  complete. 

Hepatism. — It  is  difficult  to  define  this  condition  precisely,  and  to  briefly 
indicate  the  general  disturbances  which  characterize  it,  for  the  lesions  of  the 
liver  are  numerous;  of  very  various  kinds;  often  latent  at  the  beginning,  dur- 
ing their  entire  course,  and  even  when  they  are  in  an  advanced  stage ;  and 
finally  are  manifested  by  a  sufficiently  complex  set  of  symptoms.  Neverthe- 
less it  is  correct  to  say  that  they  more  especially  affect  the  functions  of  the 
digestive  and  circulatory  apparatus,  and  that  they  interfere  with  nutrition  by 
the  changes  produced  in  the  quantity  and  quality  of  the  blood. 

Each  distinct  hepatic  lesion  (chronic  congestion,  atrophic  or  hypertrophic 
cirrhosis,  fatty  or  amyloid  degeneration,  syphiloma,  lithiasis,  biliary  reten- 
tion, cancer,  cystic  disease),  evidently  acts  after  its  own  manner  and  with 
more  or  less  intensity  upon  nutrition,  digestion,  the  peripheral  or  cardiac 
circulation,,  and  the  composition  and  genesis  of  the  blood.  But  from  the 
point  of  view  which  we  occupy,  that  is  to  say  as  far  as  concerns  the  relations 
of  affections  of  the  liver  to  injuries,  the  differences  are  not  as  marked  as  might 
be  believed.  In  tact,  in  autopsies  upon  individuals  suffering  from  hepatic 
disease,  who  have  succumbed  from  the  results  of  their  wounds,  the  most 
varied  changes  have  been  found:  fatty  degeneration,  cirrhosis,  old  perihepa- 
titis, amyloid  degeneration,  lithiasis,  cancer,  unrecognized  hydatids,  etc. 
Everything  leads  us  to  believe  that  when  the  number  of  cases  shall  be  in- 
creased, less  confused  results  will  be  obtained  ;  but,  at  the  present  time,  we 
are  compelled  to  satisfy  ourselves  with  merely  referring  to  the  influence  of 
hepatic  affections,  taken  all  together,  upon  traumatism,  and  vice  versa. 

In  the  first  place,  we  may  declare,  without  fear  of  contradiction,  that  this 
influence  is  generally  injurious ;  that  every  wound  is  serious  in  a  patient  suf- 
fering from  hepatic  disease;  that  every  such  patient  is  in  danger,  and  that  in 
case  of  such  coincidence,  the  prognosis  is  rendered  gloomy  by  each  of  the  two 
factors  in  the  morbid  association.  After  this  statement,  if  we  reflect  upon  the 
extreme  frequency  of  secondary  changes  in  the  liver;  upon  its  almost  inevitable 
implication  by  toxic  agents  such  as  alcohol,  arsenic,  and  malarial  and  septic 
poisons;  upon  its  implication  sooner  or  later  when  the  kidneys,  spleen,  or  heart 
are  chronically  affected;  upon  its  almost  certain  participation  in  all  cachexias 
(tuberculous,  cancerous,  purulent,  etc.);  we  shall  understand  what  weight 
hepatism  possesses  in  the  question  of  surgical  indications  and  contra-hid ica- 
tions,  ami  we  shall  wonder  that  a  fact  of  such  gravity  should  have  for  so  long 
a  time  remained  unrecognized. 

The  chief  complications  observed  in  these  patients,  at  the  region  of  the 
wound, are:  inflammations  of  bad  character;  bronzed, erysipelatous, and  dif- 
fuse phlegmons;  sphacelus;  wandering  erysipelas,  and,  as  a  natural  conse- 
quence of  these  local  complications,  grave  traumatic  fevers,  septh-emia  of 
an  adynamic  form,  and  pyaemia  following  a  rapid  course:  secondary  arte- 
rial, venous,  or  capillary  hemorrhages  are  especially  to  be  dreaded  on  account 
of  their  frequency  and  gravity,  and  the  slight  efficacy  of  ordinary  hemostatic 
measures.  The  blood,  moreover,  does  not  How  through  the  wounded  vessels 
only,  hut  also  escapes  at  a  distance  through  the  nasal  and  intestinal  mucous 
membranes.  Independently  of  these  acute  and  serious  accidents,  we  also  find 
in   these  patients  that  the  wound  assumes  a  bad  appearance,  remains  atonic 


HEPATISM — XEPHRISM CARDISM.  327 

and  languishing,  furnishes  an  abundant  but  serous  and  fetid  pus ;  that,  in  a 
word,  it  presents  no  tendency  to  cicatrization.  I  have  several  times  observed 
this  torpid  process  in  the  anal  region,  even  when  there  was  no  tuberculous 
lesion  present  in  the  lung. 

The  wounds,  however  free  they  may  themselves  be  from  any  unusual  phe- 
nomena, may  react  directly  upon  the  pre-existing  hepatic!  affection,  causing, 
for  example,  the  reappearance  of  jaundice,  biliary  colic,  anasarca,  ascites,  ob- 
stinate vomiting,  and  anorexia,  profuse  diarrhoea,  etc.  Under  this  disastrous 
influence,  a  patient  with  hepatic  disease  who  yet  has  been  in  a  passable  con- 
dition and  threatened  by  no  immediate  danger,  may  soon  enter  into  the  period 
of  cachexia,  and  finally  succumb  at  the  end  of  a  few  weeks  or  months.  But 
the  disturbing  action  of  the  traumatism  may  be  still  more  rapid  and  terrible. 
Thus  we  may  find  a  patient  who  suffers  from  cancer  of  the  liver,  cirrhosis,  or 
biliary  lithiasis,  sinking,  shortly  after  an  injury,  into  a  vague  condition,  bear- 
ing no  name,  and  without  any  well-defined  symptoms,  and  die  in  a  few  days, 
precisely  as  those  do  who  are  wounded  while  suffering  from  albuminuria  or 
diabetes. 

The  probabilities  of  the  appearance  of  local  complications,  or  of  the  recip- 
rocal action  of  the  injury  upon  the  hepatic  condition,  can  in  no  wise  be  deter- 
mined from  the  nature  or  gravity  of  the  injury.  Life  has  been  seriously 
threatened  or  even  destroyed  almost  as  often  in  consequence  of  slight  injuries 
(leech  bites,  paracentesis  abdominis,  opening  abscesses,  simple  fractures  and 
dislocations),  as  after  serious  operations  or  grave  wounds  (compound  fractures, 
severe  contusions,  herniotomy,  castration,  amputation,  removal  of  tumors). 

ISTephrism. — This  is  the  general  condition  observed  in  patients  suffering 
from  a  grave  renal  affection,  whether  old  or  recent.  This  condition  may  be 
acute  or  chronic,  temporary  or  prolonged,  latent  or  revealed  by  more  or  less 
evident  symptoms,  among  which  the  character  of  the  urine  occupies  the  chief 
rank. 

The  part  played  by  the  urinary  secretion  in  the  depuration  of  the  blood 
enables  us  readily  to  understand  and,  to  a  certain  extent,  foresee,  the  changes 
undergone  by  the  nutrient  fluid  when  the  renal  parenchyma  does  not  fulfil 
its  eliminating  function.  Xephrism  is  very  like  cases  of  blood-poisoning, 
with  this  difference,  that  the  poison  here  does  not  come  from  without  but  from 
within,  manifesting  its  effects  as  soon  as  it  accumulates  in  the  mass  of  blood> 
and  making  an  effort  to  escape  through  complementary  channels.  At  the 
same  time  that  they  prevent  the  necessary  expulsion  of  superfluous  and  inju- 
rious matters,  certain  renal  lesions  also  permit  the  spoliation  of  the  blood  by 
the  untoward  escape  of  useful  substances,  as  is  the  case,  for  example,  in  albu- 
minuria. The  blood,  thus  adulterated  or  impoverished,  is  ill-fitted  for  the 
nourishment  of  the  tissues ;  the  poison,  seeking  unusual  channels  of  escape, 
affects  the  various  organs,  so. that,  at  the  end  of  a  certain  length  of  time,  there 
is  a  true  disease  totius  substantias;  the  digestive  functions  are  lowered,  the  heart 
is  affected,  the  peripheral  circulation  embarrassed  ;  the  blood  escapes  from  its 
channels,  and  serum  accumulates,  especially  in  serous  or  connective  tissue 
spaces.     Finally,  the  nervous  centres  themselves  participate  in  the  disorder. 

Renal  affections,  which  are  numerous,  do  not  all  produce  nephrism  with  the 
same  rapidity  or  intensity,  but  eventually,  if  persistent,  they  all  end  by  ruin- 
ing the  organism.  Generalized,  interstitial  or  parenchymatous  nephritis, 
hydronephrosis,  and  cystic  degeneration,  are  especially  grave;  then  follow 
renal  lithiasis  and  pyelonephritis;  and  finally  fatty  and  amyloid  degeneration. 
From  a  surgical  point  of  view,  however,  we  may  repeat  what  has  been  said 
above  with  regard  to  affections  of  the  liver,  that  is  that  we  are  not  in  a  posi- 
tion to  say  which  form  of  nephritis,  for  example,  most  seriously  complicates 


328        RECIPROCAL   EFFECTS   OF   CONSTITUTIONAL   CONDITIONS   AND   INJURIES. 

injuries,  and,  in  its  turn,  receives  from  them  the  most  disastrous  aggravation. 
We  must  restrict  ourselves  to  the  statement  that  the  coincidence  of  an  injury 
and  a  renal  affection  (even  if  but  slightly  serious)  gives  occasion  for  a  very 
unfavorable  prognosis. 

The  local  complications  of  wounds  in  these  cases  are  very  similar  to  those 
which  have  been  observed  in  patients  suffering  from  hepatic  diseases.  Thus 
we  note  secondary  hemorrhages,  diffuse  inflammations  of  the  connective 
tissue  or  lymphatics,  severe  erysipelas,  sphacelus,  osteo-myelitis,  pyaemia, 
and,  as  less  serious  complications,  persistent  oedema,  extreme  slowness  of  the 
reparative  process,  interminable  serous  suppuration,  a  puffy,  bleeding,  grayish 
appearance  of  the  granulations,  etc.  The  bad  appearance  of  wounds  is  espe- 
cially noticeable  when  they  affect  tissues  which  have  been  already  infiltrated, 
as  occurs  in  cases  of  albuminuria.  To  these  unfavorable  conditions  of  the 
traumatic  centre  are  naturally  superadded  general  phenomena,  and  especially 
more  or  less  active  fever,  often  accompanied  by  chills.  Such  symptoms  must 
not  always  be  attributed  to  the  existence  of  pyaemia.  In  fact,  the  attack 
which  makes  us  fear  the  invasion  of  this  terrible  complication  may  be  simply 
of  renal  origin ;  that  is  to  say,  produced  by  the  reaction  of  the  injury  upon 
the  pre-existing  disease  of  the  kidneys.  At  the  approach  of  death,  it  is  not 
rare  to  find  a  very  marked  fall  of  temperature. 

If  local  complications  of  wounds  carry  off  a  certain  number  of  patients 
with  renal  disease  who  have  been  wounded  or  operated  upon,  death  occurs 
perhaps  still  more  frequently  from  the  inverse  action ;  that  is  to  say,  from 
the  rapid  or  progressive  aggravation  produced  by  the  traumatism  in  the  pre- 
existing renal  lesions.  Among  operations,  we  must  particularly  mention 
those  performed  on  the  urinary  apparatus  itself,  such  as  lithotomy,  lithotrity, 
and  urethrotomy,  and  also  the  incisions  rendered  necessary  by  hemorrhagic 
or  urinary  infiltrations.  If  we  suppose  them  to  have  been  properly  per- 
formed, and  the  after-treatment  judiciously  conducted,  these  operations  are 
benign  when  the  kidnej^s  are  sound  or  but  slightly  changed ;  but  things  are 
very  different  when  any  form  of  nephritis  is  present.  The  mortality  then 
becomes  considerable ;  those  operated  upon  usually  succumb  in  a  few  days 
with  the  general  lesions  which  characterize  the  last  stages  of  renal  affections 
abandoned  to  themselves,  to  wit,  diffuse  inflammations,  gangrene,  serous 
effusion  into  the  pleural  and  pericardial  cavities,  pulmonary  oedema,  and 
ursemic  accidents,  such  as  coma,  dyspnoea,  eclampsia,  etc.  Peripheral 
wounds  and  operations  may  also  lead  to  rapid  death,  even  though  the  seat 
of  traumatism  does  not  appear  abnormal ;  but  the  progress  of  the  compli- 
cations is  usually  less  violent ;  a  latent  albuminuria  becomes  evident  or  is 
aggravated  ;  nephritis  declares  itself,  with  fever,  dyspeptic  disorders,  vomit- 
ing, dryness  of  the  tongue,  etc.;  anasarca  appears  or  becomes  more  extensive. 
.Ml  may  then  do  well ;  but  it  is  not  rare  to  find  that  the  renal  affection  thus 
excited  assumes  a  progressive  course,  and  increases  continually  until  it  pro- 
duces death,  a  longer  or  shorter  period  after  the  healing  of  the  wound. 

An  injury  bus  mare  than  once  given  rise  to  the  first  appearance  or  sudden 
return  of  nephritic  colic.  Traumatisms  affecting  certain  regions  of  the  cen- 
tral nervous  system  bave  produced  albuminuria  and  polyuria,  usually,  how- 
ever, only  temporary.  AVounds  of  the  kidneys  themselves  are  serious  when 
they  give  rise  to  oliguria,  and  especially  to  anuria;  for  these  symptoms, 
though  accidentally  produced,  imply  a  condition  of  the  economy  which  is  as 
serious  as  if  tiny  resulted  from  an  old  renal  lesion.  We  shall  not  thoroughly 
understand  flic  reciprocal  influence  of  injuries  and  of  nephrism  until  it  shall 
have  been  demonstrated  that  all  wounds  modify  the  composition  of  the 
urine,  that  every  modification  of  the  urine  implies  a  corresponding  change 


LOCOMOTOR    ATAXIA   AND    VARIOUS   NEUROSES.  329 

in  the  composition  of  the  blood,  and  that  this  modification  may  in  certain 
cases  act  upon  the  reparative  process. 

Cardism. — Even  severe  disturbances  of  the  central  circulation  do  not 
derange  the  course  of  the  reparative  process,  if  they  are  temporary.  On  the 
contrary,  valvular  lesions  and  degenerations  of  the  muscular  tissue  of  the 
heart  may,  by  changing  the  static  and  dynamic  conditions  of  the  entire 
circulation,  modify  the  chemical  composition  of  the  blood,  cause  impairment 
of  important  viscera  like  the  liver  or  lungs,  alter  the  connective  tissue  which 
is  so  necessary  to  cicatrization,  and,  in  a  word,  create,  locally  as  well  as 
throughout  the  entire  economy,  conditions  which  are  very  unfavorable  to  the 
proper  evolution  of  the  process  of  cicatrization.  Thus  passive  hemorrhages, 
either  prolonged  primary,  or  early  or  late  secondary  bleedings — difficult  to 
check  in  all  cases — have  been  observed  in  patients  thus  affected,  together 
with  considerable  oedema  of  the  wounded  region,  and,  at  the  site  of  the 
swelling,  patches  of  erythema,  of  erysipelas,  and  even  of  gangrene,  such  as 
are  met  with  in  all  infiltrated  tissues,  whatever  be  the  cause  of  the  infiltra- 
tion ;  and,  finally,  a  local  atony  which  readily  metamorphoses  the  wound 
into  an  ulcer,  and  indefinitely  delays  cicatrization. 

The  reaction  of  the  injury  upon  pre-existing  cardiopathies,  is  still  more 
serious,  without  reference  to  the  grave,  even  fatal,  attacks  of  syncope  which 
may  follow  immediately  upon  the  injury.  It  is  very  frequently  found,  in 
cases  of  fatty  degeneration  of  the  heart,  that  the  circulation  and  respiration 
become  embarrassed,  and  that  the  wounded  person  rapidly  succumbs,  without 
anything  having  foretold  this  termination,  and  when  everything  has  appeared 
to  be  doing  well.  The  catastrophe  has  been  more  than  once  attributed  to  the 
efi'ect  of  chloroform,  or  to  shock,  though  simply  due  to  the  sudden  or  slow 
stoppage  of  an  already  affected  heart.  In  less  severe  cases,  the  traumatism 
merely  reveals  cardiopathies  which  had  been  hitherto  misinterpreted  or  even 
ignored  by  the  patients ;  intensifies  the  symptoms,  especially  the  anasarca 
and  serous  suffusions ;  and  increases  the  phenomena  of  oppression,  of  dyspnoea, 
by  aggravating  the  secondary  disturbances  on  the  part  of  the  lungs. 

We  possess  but  little  information  in  regard  to  wounds  in  individuals  suf- 
fering from  aneurisms  of  the  aorta.  I  nevertheless  know  of  the  rupture  of  an 
aneurismal  sac  (the  existence  of  the  blood-tumor  not  having  been  previously 
suspected)  in  consequence  of  the  simple  puncture  of  a  hydrocele.  Operations 
are  often  performed  upon  limbs  affected  by  arterial  atheroma,  and  it  is  said 
that  secondary  hemorrhage  is  to  be  apprehended  in  such  cases.  This  assertion 
does  not  appear  to  be  well  demonstrated,  and  there  is  much  more  reason  to 
fear  gangrene,  in  cases  of  contused  wound,  or  complete  or  partial  sloughing 
of  the  flaps  of  an  amputation.  There  is  also  danger  of  a  complication  which 
is  perhaps  even  more  grave ;  starting  from  the  injured  point,  the  vessels 
become  inflamed,  and  an  acute  endarteritis  descends  towards  the  periphery 
and  mounts  to  the  endocardium,  producing  all  those  consequences  which  can 
readily  be  foreseen. 


Locomotor  Ataxia  and  Various  Neuroses. 

This  disease,  which  affects  the  nutrition  of  certain  tissues,  chiefly  the  bones, 
predisposes  on  this  account  to  fractures  and  to  those  peculiar  atrophies  of  the 
epiphyses,  the  point  of  departure  of  which  is  sometimes  found  in  external 
violence.  Some  facts  also  tend  to  prove  that  cicatrization  progresses  slowly 
or  imperfectly  in  the  wounds  of  ataxic  patients. 

The  reciprocal  influence  of  traumatism  upon  ataxia  is  better  established. 


330        RECIPROCAL    EFFECTS    OF    CONSTITUTIONAL    CONDITIONS    AND    INJURIES. 

In  the  first  place,  wounds  which  involve  the  spine  directly  and  the  spinal 
cord  indirectly,  readily  give  rise  to  chronic  myelitis,  the  symptomatology  of 
which  is  very  like  that  of  ataxia,  in  certain  cases.  It  has  been  asserted  that 
wounds  affecting  the  limbs,  that  is  to  say  at  a  distance  from  the  spinal  cord, 
may  also  give  rise  to  ataxia.  This  is  doubtful,  and  it  is  much  more  probable 
that  the  violence  merely  plays  the  part  of  an  exciting  cause  giving  rise  to  the 
premature  appearance  of  the  phenomena  in  predisposed  subjects.  At  all 
events,  there  is  no  doubt  that  ataxia  is  usually  exaggerated  and  aggravated  by 
injuries,  whether  or  not  they  affect  the  region  of  the  spine.  It  has  been  held 
that  certain  operations  favorably  modify  or  even  cure  ataxia.  But  this  is  a 
mistake;  this  affection  has  been  confounded  with  nervous  disorders  of  re- 
flex origin,  which  have  been  relieved  by  removing  the  point  of  peripheral 
departure.  Injuries  sometimes  present,  in  neuropathic  individuals,  a  defec- 
tive evolution  and  numerous  local  complications ;  analgesia,  hypera?sthesia, 
simple  or  hemorrhagic  congestion,  lesions  of  the  granular  membrane,  delay  in 
cicatrization,  etc.  As  a  result  of  wounds  of  nerves,  and  of  limbs  formerly 
affected  by  infantile  or  other  forms  of  paralysis,  superficial  or  deep  ulcera- 
tions are  found  to  occur,  which  are  attributed  to  trophic  disturbances,  and 
which  are  at  all  events  very  painful  and  extremely  difficult  to  heal,  especially 
in  winter.  Reciprocally,  in  the  same  neuropathic  patients,  an  injury  may 
excite,  revive,  or  exaggerate  nervous  manifestations  which  assume  the 
strangest  forms,  and  which  attack  the  central  and  visceral  nervous  systems, 
as  well  as  general  motion  and  sensation. 

Among  defined  neuroses,  hysteria  and  epilepsy  present  close  relations  to 
traumatism.  In  addition  to  the  fact  that  they  sometimes  seem  to  be  directly 
due  to  injuries,  affecting  especially  the  genital  apparatus  in  woman,  and  the 
brain  in  both  sexes,  it  is  certain  that  wounds  of  the  most  diverse  character  as 
regards  situation  and  extent,  have  the  power  of  exciting  hysterical  or  epilep- 
tic attacks,  often  indeed  with  extreme  violence.  On  the  other  hand,  we  find 
mention  made  by  authors  of  more  than  one  case  of  epilepsy  cured  by  an  acci- 
dental wound  or  by  premeditated  operation.  There  has  been  considerable 
discussion  as  to  whether  insane  persons  tolerate  wounds  better  or  worse  than 
other  individuals,  and  the  most  contradictory  facts  have  been  adduced  in  re- 
gard to  the  matter.  The  fact  is  that  it  is  impossible  to  class  together  the 
subjects  of  mania  and  those  of  dementia  ;  those  who  are  excited,  with  the 
victims  of  general  paralysis  ;  those  whose  brains  are  affected  by  alcoholism 
and  those  affected  by  old  wounds.  With  such  a  variety,  it  is  neither  possible 
nor  useful  to  attempt  a  generalization ;  and  a  detailed  investigation  would 
not  be  in  place  in  a  work  of  this  character. 


Diabetes  Mellitus. 

All  are  agreed  concerning  the  unfavorable  course  of  wounds  and  the  gravity 
of  operations  in  diabetic  patients.  The  reparative  process  is  often  absent,  or 
at  hast  very  slow,  and  interrupted  by  numerous  complications.  In  open 
wounds  are  noticed  primary  capillary  hemorrhages,  which  are  difficult  to 
arrest,  and  also  secondary  hemorrhages;  in  contused  wounds,  diffuse  inflam- 
mation, bronzed  phlegmons,  and  extensive  sloughing.  Insignificant  wounds 
such  as  punctures  and  excoriations,  become  inflamed  and  provoke  lymphan- 
geitis,  erysipelas,  and  phlegmons  which  become  complicated  by  gangrene 
en  masse  or  in  isolated  patches,  and  the  progress  of  which  is  with  great  diffi- 
culty arrested.  Slight  operations,  followed  by  immediate  union,  have  often 
presented  similar  complications.  Even  the  moderate  pressure  of  an  apparatus 
hae  produced  circumscribed  gangrene  of  the  skin.     Subcutaneous  wounds  are 


PHOSPHATURIA.  331 

less  serious,  but  fractures  unite  with  great  difficulty.  Diabetic  phlegmon  and 
gangrene  sometimes  progress  slowly  and  without  provoking  an}'  very  violent 
or  grave  general  symptoms,  but  they  none  the  less  terminate  in  death,  in  the 
majority  of  cases,  especially  in  old  persons  whose  internal  organs  are  in  a 
bad  condition,  and  when  suitable  treatment  has  not  been  employed  in  time. 
Traumatism  affecting  the  region  of  the  medulla  oblongata,  either  directly  or 
indirectly,  may,  as  is  well  known,  produce  glycosuria  which  is  usually  of  short 
duration,  and  which  undergoes  spontaneous  cure. 

Wounds  affecting  a  diabetic  subject  generally  aggravate  his  condition. 
The  sugar,  which  had  disappeared,  shows  itself  again,  or  becomes  more  abund- 
ant. This  is  espeeially  observed  in  operations  upon  those  who  have  been 
previously  recognized  as  diabetic,  and  in  whom  the  sugar  has  been  made  to 
disappear  from  the  urine.  This  return  of  glycosuria  may  be  temporary,  but 
it  may  also  hasten  the  development  and  natural  termination  of  the  disease. 
Wounded  diabetics  may  recover,  but  they  may  die  in  several  ways ;  in  the 
first  place,  from  inflammatory  or  septic  complications  which  have  started  in 
the  wound ;  then  of  complications  on  the  part  of  the  brain,  heart,  or  lungs ; 
and  finally  they  may  rapidly  die  in  a  sort  of  adynamic  condition  which  we 
cannot  attribute  to  any  well-defined  local  or  general  complications.  The 
gravity  of  the  prognosis  is  greater  as  the  wound  or  operation  is  more  serious, 
as  the  quantity  of  sugar  is  larger,  and  as  the  diabetes  is  accompanied  with 
more  advanced  visceral  lesions. 

The  distinction  established  by  modern  writers  between  glycosuria  and  dia- 
betes is  admissible  to  a  certain  extent,  but  we  must  not  trust  to  it  too  much, 
and  regard  as  benign  those  wounds  which  occur  in  individuals  who  pass  but 
little  sugar.  It  is  equally  incorrect  to  regard  as  favorable  the  substitution  of 
albumen  for  sugar  in  certain  diabetics.  Except  in  urgent  cases,  we  should 
never  operate  upon  a  diabetic  patient,  until  we  have  made  the  sugar  disap- 
pear as  much  as  possible  from  the  urine. 

Alcohol-diabetes. — Although  it  has  not  yet  been  referred  to,  the  associa- 
tion of  alcoholism  and  diabetes  cannot  be  very  rare,  if  we  take  into  account, 
on  the  one  hand,  the  polydypsia  natural  to  diabetics,  and,  on  the  other,  the 
advice  given  these  patients  to  take  stimulating  drinks.  As  poisoning  by  alco- 
hol and  poisoning  by  sugar  both  give  rise  to  quite  similar  complications  in 
the  traumatic  centre — diffuse  inflammation,  erysipelas,  gangrene — it  is  not  sur- 
prising to  find  that  in  the  subjects  of  alcohol-diabetes,  wounds,  which  were 
at  first  slight,  are  followed  by  serious  and  rapid  complications.  Thus,  I  have 
seen  a  puncture  or  contusion  cause  very  extensive  sloughing,  and  catheteriza- 
tion give  rise  to  double,  rapidly  fatal  nephritis.  While  an  autopsy  often  gives 
negative  results  in  cases  of  simple  diabetes,  in  those  cases  of  alcohol-diabetes 
which  I  have  seen,  grave  visceral  lesions  have  been  noted — cirrhosis,  old  peri- 
nephritis, double  nephritis — which  were  very  probably  the  results  of  the  alco- 
holism, and  which  would  by  themselves  have  given  rise  to  the  fatal  termina- 
tion without  the  concurrence  of  the  diabetes.  More  numerous  observations 
will  permit  further  study  of  this  interesting  variety  of  hybrid  disease. 

Phosphaturia. 

Glycosuria  is  not  the  only  form  of  diabetes ;  in  the  same  rank  must  be 
placed  simple  polyuria,  or  diabetes  insipidus;  phosphaturia,  or  phosphatic 
diabetes ;  azoturia,  and  finally  uric  diabetes,  which  alternates  so  frequently 
with  diabetes  mellitus.  Who  knows  indeed  whether  the  list  will  not  become 
more  extensive,  and  whether  it  will  not  be  necessary,  at  some  future  period, 


332         RECIPROCAL    EFFECTS    OF    CONSTITUTIONAL    CONDITIONS    AND    INJURIES. 

to  add  the  exaggerated  elimination  of  the  chlorides,  or  of  any  other  sub- 
stances contained  in  the  urine?  For  the  present,  I  have  but  little  to  say  in 
regard  to  the  relations  existing  between  injuries  and  these  various  forms  of 
diabetes.  In  a  very  large  and  stout  man  a  slight  contused  wound  of  the  leg 
did  not  heal,  and  tended  to  become  transformed  into  an  ulcer.  Examination 
of  the  urine  showed  that  the  patient  was  azoturic  to  a  high  degree.  On  the 
other  hand,  a  young  scrofulous  individual  passed  daily  from  12  to  15  litres 
[121  to  16  quarts]  of  urine  as  clear  as  water.  Disarticulation  of  the  first  meta- 
tarsal bone  had  to  be  performed  ;  it  was  followed  by  no  complication,  and  the 
wound  healed  without  delay  or  difficulty. 

I  have  collated  more  abundant  and  more  interesting  material  with  regard 
to  phosphaturia.  It  has,  in  the  first  place,  appeared  to  me  to  play  an  im- 
portant part  in  fragilitas  ossium,  and  in  the  spontaneous  fractures  which  occur 
without  previous  circumscribed  lesions.  Certain  facts  would  permit  us  even 
to  establish  relationships  between  organic  affections  of  the  bones  and  phos- 
phaturia, although  it  is  impossible  to  decide  whether  the  latter  be  cause  or 
effect.  We  will  often  find  an  exaggerated  elimination  of  phosphates  in  eases 
of  polyuria  in  scrofulous  children  suffering  from  osteitis.  I  have  several  times 
observed  the  disastrous  influence  exercised  by  phosphaturia  upon  the  local 
progress  of  injuries.  I  have  noted,  for  example,  a  consecutive  hemorrhage,  a 
diffuse  phlegmon,  orange-colored  suppuration,  purulent  destruction  of  the  eye 
after  the  operation  for  cataract,  marked  delay  in  the  union  of  fractures,  etc. 

As  a  sequel  to  well-characterized  maladies,  it  would  be  proper  to  study,  in 
their  relations  to  accidental  or  surgical  injuries,  certain  temporary  states  which 
assuredly  are  not  pathological  in  "the  literal  sense  of  the  word,  and  yet  during 
the  duration  of  which,  the  organism  finds  itself  under  peculiar  conditions. 
These  states  include  dentition,  puberty,  menstruation,  the  menopause,  pregnancy, 
the  'puerperal  state,  and  lactation.  In  the  opinion  of  the  public,  these  con- 
ditions have  a  very  manifest  influence  upon  previously  existing  or  inter- 
current diseases,  and  it  would  be  very  useful  to  know  exactly  whether  it  were 
the  same  in  regard  to  wounds.  The  question  of  surgical  interference,  also, 
arises  very  frequently  in  the  two  extreme  periods  of  life,  infancy  and  old  age. 
Opinions  differ  widely  as  to  the  course  of  injuries  and  the  manner  in  which  they 
are  tolerated  under  these  circumstances.  Unfortunately  we  have  not  sufficient 
materials  to  clear  up  all  these  problems  ;  we  barely  possess  a  few  facts  in  re- 
gard to  pregnancy  and  the  puerperal  state,  and  to  operations  in  childhood  and 
old  age.  .  I  give  here  a  brief  summary  of  what  is  known  to  science  upon 
these  subjects. 

Pregnancy. 

This  question  was  debated  at  length  in  the  International  Congress  of 
Geneva,  in  1877.  It  was  established  that  pregnancy  and  traumatism  may 
run  their  course  parallel  to  each  other  in  a  normal  manner,  without  influ- 
encing cadi  other  in  the  slightest  degree, even  when  the  injuries  are  extremely 
severe;  thai  pregnancy  may  disturb  the  reparative  process  by  delaying  or 
hindering  healing,  and  by  giving  rise  to  various  wound-complications  at  the 
injured  poinl  ;  it  may  also  aggravate  certain  non-traumatic  affections  in  such 
a  manner  as  to  render  necessary  and  even  urgent,  operations  which,  in  the 
non-pregnan1  condition,  could  have  been  avoided  or  postponed.  The  delay  or 
hindrance  in  the  healine  of  wounds,  which  is  produced  by  pregnancy,  may 
cease  immediately  after  delivery,  which  restores  to  the  reparative  tendency  all 
its  power. 

Accidental  or  operative  wounds,  even  the  slightest,  may  interfere  with 


PREGNANCY.  333 

gestation  in  several  ways :  by  provoking  abortion  or  premature  delivery ;  by 
causing  the  death  of  the  mother  with  or  without  that  of  the  child,  and  either 
before  or  after  that  of  the  child. 

The  normal  termination  of  the  pregnancy,  that  is  to  say  the  reciprocal 
independence  of  the  traumatism  and  of  the  pregnancy,  may  be  foreseen  and 
announced :  when  the  wound  is  remote  from  the  genital  apparatus ;  when  it 
affects  healthy  tissues ;  when  it  is  slight,  simple,  and  not  complicated  pri- 
marily or  consecutively  by  any  accident  capable  of  transforming  the  wounded 
person  into  a  sick  one  ;  and  when,  on  the  other  hand,  the  uterus,  the  foetus,  and 
its  annexes,  are  anatomically  and  physiologically  normal,  and  when  the  ma- 
ternal organism,  which  has  been  suddenly  subjected  to  the  injury,  is  sound  or 
nearly  so,  that  is  to  say  free  from  all  constitutional  disease  existing  either 
before  or  after  fecundation,  and  when  it  remains  so  afterwards. 

The  injurious  influence  of  traumatism  upon  pregnancy  and  the  various  ter- 
minations which  follow,  may,  in  turn,  be  foreseen  and  declared :  when  the 
wound  affects  the  foetus  and  its  annexes,  the  uterus,  and  the  other  organs 
pertaining  to  the  genital  sphere,  and  when  these  parts  are,  in  advance,  altered 
in  various  ways ;  when  the  wound  is  extensive  or  grave  in  itself,  or  when  it 
affects  organs  essential  to  the  life  of  the  mother ;  when  the  mother  has  suf- 
fered, before  the  reception  of  the  wound,  from  a  constitutional  morbid  condi- 
tion, or  from  a  circumscribed  affection  which  renders  abortion  possible  and 
probable ;  or  when  some  complication  starts  from  the  wound  or  its  immediate 
neighborhood,  and  is  at  all  events  capable  of  weakening,  shattering,  or  poi- 
soning the  maternal  or  foetal  organisms. 

We  may  hope  for  and  declare  the  favorable,  though  indirect,  action  of  sur- 
gical traumatism  upon  pregnancy,  when,  by  the  aid  of  even  a  serious  opera- 
tion, we  can  succeed  in  removing  an  affection  which  is  still  more  dangerous 
to  mother  and  child. 

The  aggravation  of  certain  morbid  conditions  in  the  pregnant  woman  is 
explained  by  the  general  or  local  modifications  which  pregnancy  produces  in 
the  circulation,  in  nutrition,  in  the  composition  of  the  blood,  and  in  the  gene- 
sis of  anatomical  elements ;  and  in  the  same  manner  is  explained  the  favor- 
able action  of  delivery,  which  suppresses  various  pathogenetic  causes.  We 
can  understand  the  hurtful  effect  of  the  puerperal  condition  upon  trauma- 
tism contracted  after  delivery,  if  we  take  into  consideration  the  conditions 
then  presented  by  the  injuries  which,  in  fact,  often  involve  tissues  that 
are  altered,  or  profoundly  modified  in  their  structure  and  properties ;  indi- 
viduals already  wounded  by  the  mere  fact  of  the  uterine  trauma ;  women 
already  sick  in  consequence  of  pregnancy  itself  or  of  the  constitutional  condi- 
tions which  may  be  associated  with  it.  Whenever  a  woman,  during  the 
period  of  fecundity,  is  wounded  accidentally  or  as  the  result  of  a  surgical 
operation,  we  should  always  determine  whether  she  is  in  a  condition  of  preg- 
nancy or  not.  In  the  former  event,  we  should  note  with  extreme  care,  imme- 
diately after  the  injury  or  before  the  operation,  the  organic  conditions  of  the 
mother,  the  state  of  her  genital  apparatus,  and  that  of  the  product  of  concep- 
tion. In  case  of  an  accidental  injury,  the  local  and  general  treatment  should 
be^  directed  to  moderating  or  preventing  the  direct  or  indirect,  disastrous 
effects  of  the  wound  upon  the  genital  apparatus  ;  to  maintaining  the  patient 
in,  or  restoring  her  to,  the  condition  of  one  who  is  simply  wounded,  and  to 
prevent  her  from  being  changed  into  one  who  is  sick  ;  to  palliating  or  com- 
bating every  injurious  effect  of  pregnancy  upon  the  reparative  process ;  in  a 
word,  to  preventing  abortion. 

When  abortion  occurs,  we  should  watch  the  wound  to  ward  off"  any  possible 
aggravation,  and  the  uterus  to  prevent  the  septicaemia  of  which  it  is  sometimes 
the  starting-point  and  the  seat. 


334        RECIPROCAL    EFFECTS   OF   CONSTITUTIONAL   CONDITIONS   AND   INJURIES. 

Surgical  interference  is  not  interdicted  during  pregnancy,  but  is  subject  to 
special  rules.  We  should  operate  upon  a  pregnant  woman  with  the  greatest 
reserve,  and  sometimes  refuse  absolutely;  but  it  would  be  an  equally  grave 
fault  to  abstain  systematically  in  all  cases.  The  affections  which  are  amenable 
to  operation — more  numerous  during  gestation  than  during  the  non-pregnant 
state — are  divided  into  several  categories  which  suggest  the  following  rules 
of  practice : — 

To  operate  at  once  in  those  affections  which  immediately  endanger  the  life 
of  the  mother,  and  against  which  medical  treatment  would  be  certainly  or 
almost  certainly  unavailing  ; 

To  operate  also,  at  a  suitable  time,  and  after  having  tried  palliative  or 
curative  remedies,  in  those  diseases  which,  although  not  immediately  com- 
promising life,  endanger  it  by  their  progress,  and  tend  to  become  incurable  if 
not  met  with  energetic  treatment  ; 

To  operate  also  in  those  affections  which,  without  disturbing  pregnancy 
and  without  being  aggravated  by  it,  become,  at  its  termination,  causes  of 
dystocia.  In  these  cases,  the  surgeon  may  operate  before  or  at  the  very 
period  of  delivery,  upon  the  mother  or  upon  the  foetus,  the  premature  expul- 
sion of  which  may  be  induced.  An  attempt  should  be  made  to  save  both 
the  maternal  and  foetal  lives,  but,  if  this  be  impossible,  the  latter  must  be 
unhesitatingly  sacrificed  to  the  former ; 

To  abstain,  as  far  as  possible,  in  those  affections  which  are  uninfluenced  by 
pregnancy — and  which,  in  turn,  only  compromise  pregnancy  and  parturition 
indirectly — by,  as  far  as  possible,  allowing  nature  to  act,  and  by  aiding  her 
by  mild  measures ; 

To  abstain  absolutely  from  every  operation  for  affections  which  compromise 
only  the  form  or  function  of  organs  of  secondary  importance,  or  wdiich  are 
susceptible  of  spontaneous  cure  after  delivery  ; 

To  avoid,  as  far  as  possible,  every  operation  during  the  puerperal  state. 
In  case  of  danger,  to  operate  rather  during  pregnancy,  and,  under  opposite 
circumstances,  to  postpone  interference  until  a  period  sufficiently  remote 
(two  to  four  months)  from  delivery. 


Infancy. 

The  benignity  of  wounds  and  surgical  operations  in  children  is  universally 
admitted,  and  the  explanation,  moreover,  is  simple.  In  fact,  at  this  period 
of  life,  constitutional  diseases  are  not  deeply  rooted,  but  of  recent  date;  the 
viscera  are  lor  the  most  part  healthy ;  and  connective-tissue  proliferation  and 
regeneration  of  tissues  occur  with  promptness  and  energy,  etc.  We  must 
not,  however,  regard  this  benignity  as  a  rule  without  exceptions.  Athrepsic 
children,  poorly  nourished,  syphilitic,  or  tubercular,  or  who  suffer  from 
calculus  with  nephritis,  readily  fall  a  prey  to  the  consequences  of  their 
wounds. 

In  this  long  period  of  childhood,  moreover,  we  should  establish  categories 
according  to  the  age, and  consider  also  the  particular  variety  of  operation  which 
is  in  question.  The  new-horn,  for  example,  support  loss  of  blood  and  restricted 
diel  very  badly  ;  and  the  resulting  contra-indieations  continue  at  least  until 
the  twelfth  or  fifteenth  month.  It  is  for  this  latter  reason  that  we  postpone 
until  the  fourth  or  fifth  year,  if  not  later,  complicated  operations  upon  the 
mouth,  lips,  hard  or  soft  palate,  etc.  The  small  size  of  the  parts  also  relegates 
to  the  period  of  late  childhood  certain  anaplastic  operations  upon  the  penis 
and  lingers.  Finally,  we  wait  still  longer  before  undertaking  the  cure  of 
certain  imperforations  in  the  female  sex. 


OLD    AGE.  335 


Old  Age. 


Some  old  people,  whom  we  should  rather  call  aged  than  old,  tolerate  trau- 
matic lesions  as  well  as  adults.  In  others,  on  the  contrary,  the  reparative 
process  remains  imperfect.  Interstitial  wounds  suppurate ;  immediate  union 
fails ;  local  inflammations  do  not  remain  circumscribed ;  gangrene  attacks 
the  detached  and  thinned  integument ;  simple  fractures  unite  slowly  ;  severe 
contusions  are  complicated  by  diffuse  phlegmon  and  sloughing.  At  other 
times,  the  seat  of  traumatism  remains  indolent,  without  tone,  and  languish- 
ing ;  but  threatening  internal  inflammations  are  set  up ;  pneumonia,  nephritis, 
meningo-encephalitis  declare  themselves,  followed  by  their  train  of  general 
adynamic  or  ataxic  symptoms,  and  death  promptly  ensues.  The  autopsy 
almost  always  reveals  a  previously  existing  bad  condition  of  the  great  viscera, 
which  entails  the  same  consequences  as  in  adults.  In  individuals  who  are 
apparently  healthy  despite  advanced  age,  the  organs  have  sufficed  for  the 
needs  of  a  regulated  and  tranquil  life;  the  traumatism  occurs,  gives  a  shock 
to  the  economy,  stirs  up  old  morbid  susceptibilities,  and  destroys  an  organi- 
zation which  has  only  maintained  itself  in  equilibrium,  as  it  were,  by  accident. 


GENERAL  PRINCIPLES  OF  SURGICAL  DIAGNOSIS. 


BY 


D.  HAYES  AGNEW,  M.D.,  LL.D., 

BARTON  PROFESSOR  OF  SURGERY  IN   THE   UNIVERSITY  OF  PENNSYLVANIA,  SURGEON  TO  THE  PENNSYLVANIA 

HOSPITAL,  PHILADELPHIA. 


Operative  Medicine  must  be  based  on  exact  knowledge.  The  cunning  of 
the  hand  can  be  safely  directed  only  by  the  wisdom  of  the  head.  To  be  able 
to  discriminate,  with  accuracy,  the  various  morbid  conditions  of  the  human 
body,  is  the  highest  qualification  of  a  physician.  Such  knowledge  can  only 
be  attained  by  large  experience,  by  habits  of  close  observation,  by  the  ability 
to  logically  dispose  of,  or  classify,  phenomena,  and  by  the  possession  of  a 
sound  judgment.  In  the  formulation  of  phenomena  gleaned  from  the  domain 
of  physics,  the  student  is  concerned  with  matter  alone,  the  behavior  of  which 
is,  under  like  circumstances,  uniform.  The  physician  also  has  to  deal  with 
material  forms,  but  these  forms  are  instinct  with  life  and  intelligence,  factors 
which  necessarily  render  the  problem  for  study  vastly  more  complex  and  more 
difficult  of  solution.  It  is,  consequently,  no  easy  task  to  accurately  interpret  the 
phenomena  of  disease,  and  to  ascertain  with  absolute  certainty  its  true  nature; 
and  yet  it  is  only  when  such  knowledge  has  been  obtained  that  the  physician 
or  surgeon  can  safely  venture  to  administer  remedies  or  to  counsel  operations. 

The  diagnostician,  to  be  properly  equipped,  must  have  cultivated  an  exten- 
sive domain  of  study.  Anatomy,  Physiology,  Pathology,  Chemistry,  Physics, 
and  Mental  and  Moral  Philosophy,  constitute  the  foundations  of  diagnostic 
knowledge. 

In  pursuing  the  investigation  of  surgical  disease,  two  methods  are  practised, 
namely,  the  analytical  and  the  synthetical.  By  the  first,  the  surgeon  com- 
mences his  inquiries  at  the  origin  of  the  affection,  and  traces  it  down  to  the 
time  of  the  investigation ;  by  the  second  plan,  the  examination  commences 
with  the  present  phenomena,  and  follows  them  back  to  the  beginning  of  the 
disease.  Generally  the  first  or  analytical  method  is  pursued",  although  the 
latter,  or  synthetical,  will,  in  certain  instances,  be  found  preferable. 

The  examination  will,  in  the  largest  number  of  cases,  be  most  successful 
when  it  is  introduced  by  eliciting  a  general  history  of  the  complaint,  and 
afterwards  obtaining  particulars.  Such  a  course  is  less  embarrassing  to  the 
patient,  and  tends  to  establish  the  practitioner  in  his  or  her  confidence.  The 
obscurity  which  attends  some  cases  may  require  that  both  the  analytical  and 
the  synthetical  methods  shall  be  employed,  and  even  then,  it  is  not  impossible 
that  the  secret  of  disease  may  defy  and  baffle  the  tactics  of  the  wisest  diag- 
nostician. 

Whenever  the  surgeon  is  compelled  to  abandon  certitudes,  and  to  base  his 

opinion  on  probabilities,  he  is  on  dangerous  ground,  and  should  either  advance 

cautiously  or  not  advance  at  all;  the  latter  course  should,  by  all  means,  be 

adopted  when  there  is  no  urgency  for  active  measures  to  be  taken.     A  few 

vol.  i.— 22  (  337  ) 


338  GENERAL   PRINCIPLES   OF   SURGICAL    DIAGNOSIS. 

hours'  delay  will  often  clear  away  all  obscurity,  and  render  perfectly  plain 
problems  which  were  before  insoluble. 

Difficulties  in  Surgical  Diagnosis. 

The  difficulties  which  environ  the  investigation  of  disease,  arise  from  several 
sources.  Among  these  may  be  mentioned  the  reluctance  with  which  many 
consent  to  communicate  any  information  calculated  to  affect  unfavorably  the 
social  or  physical  standing  of  themselves  or  those  who  may  be  related  to  them 
by  consanguinity.  This  difficulty  can  be  overcome  only  by  the  personal  tact 
of  the  surgeon.  In  this  matter  there  exist  very  great  differences  among 
practitioners.  Some  men,  either  from  constitution  or  education,  are  unfor- 
tunate in  never  being  able  to  secure  the  entire  confidence  of  a  patient,  while 
others,  more  favored^ by  a  kind,  sympathetic  manner,  an  insinuating  address, 
and  other  amenities  which  impart  a  loadstone  attraction  to  character,  will,  in 
a  few  minutes,  obtain  such  a  mastery  over  the  will  and  the  affections  of  the 
patient,  that  nothing  will  be  withheld.  There  are  also  constitutional  pecu- 
liarities and  idiosyncrasies,  which  impart  to  the  phenomena  excited  by  morbid 
impressions  unusual  characteristics,  altogether  dissimilar  to  those  developed 
in  most  persons  under  the  operation  of  like  causes.  The  similarity  of  the 
morbid  phenomena,  which  may  result  from  diseases  altogether  unlike,  con- 
stitutes another  source  of  embarrassment,  as  do  also  the  wide  range  of  sym- 
pathy which  prevails  in  the  human  body,  and  the  reflex  impressions  which 
tend  to  disguise  their  original  source,  thus  diverting  the  attention  from  the 
real  to  the  unreal. 

The  interrogation  of  a  patient,  like  that  of  an  unwilling  witness  in  a  court 
of  justice,  requires  considerable  skill.  Sometimes  it  is  desirable 'to  allow  the 
patient  to  narrate  the  history  of  his  own  case,  provided  that  he  adheres 
strictly  to  the  subject  of  inquiry,  and  does  not  wander  off  into  useless  digres- 
sions, or  matters  altogether  non-essential.  A  license  of  this  kind  will  often 
disclose  peculiarities  "of  character  which  will  prove  of  value  in  the  general 
estimation  of  the  case. 

Questions  should 'be  put  in  plain  words,  free  from  all  ambiguity  and  from 
technical  terms.  The  answers  of  the  patient  should  be  as  brief  and  concise  as 
possible,  or  as  may  be  consistent  with  furnishing  the  desired  information. 
In  order  to  secure  exactness  and  brevity  of  statement,  no  leading  or  sugges- 
tive questions  should  be  asked.  Undue  levity  of  manner,  either  in  interroga- 
tion, or  as  excited  by  the  language  used  by  the  patient,  is  to  be  deprecated. 
Such  a  manner  is  calculated  to  wound  the  sensibilities  of  the  sufferer,  and 
lays  the  profession  open  to  the  charge  of  being  unfeeling.  It  is  not  to  be 
expected,  that  the  uneducated  should  describe  their  sensations  in  grammati- 
cally constructed  sentences,  or  in  the  most  fitting  words. 

When  it  becomes  necessary  to  question  women  on  matters  of  a  private 
nature,  the  inquiries  should  be  framed  in  the  most  delicate  language,  and 
should  never  be  pressed  beyond  the  strict  bounds  of  propriety,  or  from 
motives  of  curiosity.  With  young  women,  much  embarrassment  is  avoided 
l»v  addressing  the  questions,  and  obtaining  the  answers,  through  a  mother  or 
elderly  friend,  rather  than  directly  to  and  from  the  patient. 

The  influence  of  disease  in  changing  the  morale  of  the  sick  must  never  be 
forgotten.  Under  morbid  influences,  the  most  amiable  character  may  be 
transformed  into  cue  which  is  fretful,  irascible,  or  morose;  and  hence  the 
necessity  on  the  part  of  the  surgeon  of  making  due  allowance  for  deportment 
which,  under  other  circumstances,  would  be  regarded  as  uncivil  and  inexcus- 
able. 


GENERAL    EXAMINATION:    HISTORY   OF   THE    CASE.  339 

Unless  absolutely  necessary,  no  exposure  of  the  person  should  be  made  in 
conducting  examinations;  nor  should  the  use  of  instruments  be  repeated 
oftener  than  the  nature  of  the  case  demands.  In  fine,  the  strictest  formality 
and  absence  of  familiarity  ought  to  be  maintained  between  the  surgeon  and 
his  patient,  alike  with  the  poor  and  unlettered,  as  with  the  rich  and  cul- 
tured. 

In  the  examination  of  a  case,  whether  medical  or  surgical,  the  inquiry  will 
be  both  general  and  special.  In  the  former,  or  general  examination,  the  ques- 
tioner endeavors  to  obtain,  from  the  patient  or  his  friends,  a  history  which 
will  include  the  particulars  of  age,  sex,  social  condition,  habits,  occupation, 
residence,  family  antecedents,  etc.  The  special  inquiry  will  be  confined  to 
obtaining  such  information  as  may  be  learned  by  a  personal  examination. 


General  Examination:  History  of  the  Case. 

Aoe. — The  influence  of  age  in  giving  shape  to  surgical  inquiries,  and  in 
solving  the  problem  of  disease,  is  very  important.  The  notable  irritability 
of  the  nervous  system  in  childhood  and  adolescence,  impresses  a  peculiar 
physiognomy  on  most  of  the  affections  belonging  to  infantile  life.  For  ex- 
ample, the  irritation  of  a  resisting  gum,  in  dentition,  may  be  reflected  to  the 
remotest  parts  of  the  body,  and  may  cause  the  most  disorderly  and  spasmodic 
action  of  the  entire  muscular  system.  Such  phenomena,  when  occurring  in  an 
adult,  would  be  referred  to  an  entirely  different  source,  and  would  excite  ap- 
prehension of  a  much  graver  state  of  things  than  when  the  subject  is  a  child. 
A  pain  in  the  knee,  in  a  child,  would  immediately  direct  attention  to  the 
hip-joint.  Abdominal  pains  and  grunting  respiration  would  suggest  the  pos- 
sibility of  disease  of  the  vertebra?.  Cervical  enlargements,  which  in  the 
adult  probably  would  be  regarded  as  cysts,  carcinomata,  or  sarcomata,  would 
in  the  child  be  construed  as  adenomata. 

Vesical  irritation  in  children  suggests  the  presence  of  urinary  calculus, 
while  in  a  person  advanced  in  life,  the  same  symptoms  would  be  referred  to 
cystitis  or  to  an  enlarged  prostate.  In  lesions  resulting  from  violence,  affect- 
ing the  extremities  of  bones  in  children,  the  probability  of  a  separation  of  the 
epiphysis,  an  accident  which  could  not  occur  in  an  adult,  would  necessarily 
enter  into  the  consideration  of  the  case.  A  force  which  in  a  young  adult 
would  cause  a  fracture  at  the  upper  end  of  the  femur,  external  to  the  capsu- 
lar ligament,  would  be  likely,  in  an  individual  over  fifty  or  sixty  years  of 
age,  to  produce  a  similar  lesion  within  the  joint.  Finally,  the  diseases  pecu- 
liar to  childhood  are  the  different  exanthemata,  as  scarlet  fever,  measles,  etc.; 
inflammatory  affections  of  the  upper  part  of  the  alimentary  and  respiratory 
passages — as,  for  example,  tonsillitis,  diphtheria,  laryngitis,  and  tracheitis — 
are  also  common  in  youth.  In  middle  life,  inflammatory  attacks  affecting  the 
thoracic,  abdominal,  and  cranial  viscera,  are  most  commonly  met  with  ;  while 
in  advanced  life,  the  characteristic  maladies  are  such  as  affect  the  genito- 
urinary organs,  or  cause  structural  degenerations  in  the  bloodvessel  system. 

Sex. — There  exists  such  a  radical  difference  between  the  physical  and  psy- 
chical nature  of  the  two  sexes  in  health,  that  it  is  reasonable  to  expect  that 
their  peculiarities  should  be  intensified  under  the  perturbing  operation  of 
disease.  In  the  moral  constitution  of  women,  the  emotional  element  prepon- 
derates, and  in  the  physical  organization,  the  sexual  system.  The  reaction  of 
the  latter  on  the  former  imparts  a  coloring  to  all  morbid  phenomena — hence 
the  hysterical  convulsions,  hysterical  joints,  fictitious  blindness,  irritable 
bladder,  etc.,  which  are  encountered  during  the  active  period  of  the  uterine 


340  GENERAL   PRINCIPLES   OF   SURGICAL   DIAGNOSIS. 

and  ovarian  functions ;  while  after  the  climacteric  has  been  passed,  woman 
often  becomes  the  prey  of  those  horrid  fibroid  and  carcinomatous  neoplasms 
which  attack  the  uterus  and  the  mammary  glands.  Men,  on  the  contrary, 
enjoy  a  singular  exemption  from  hysteroidal  attacks,  as  they  also  do  from 
carcinoma.  If  a  man  complains  of  uneasiness  or  pain  in  a  joint,  it  is  gene- 
rally real — rheumatic,  gouty,  or  symptomatic  of  some  other  form  of  inflam- 
mation— and  not  a  mimicry  of  disease ;  if  a  limb  suddenly  loses  its  power,  the 
paralysis  is  real,  and  not  a  simulation ;  if  an  irritable  bladder  is  developed, 
there  is  a  reasonable  certainty  that  there  is  a  true  physical  basis  for  the  dis- 
turbance, such  as  stone,  cystitis,  or  an  enlarged  prostate.  Should  he  become 
the  subject  of  cancer,  the  disease  will  most  likely  prove  to  be  of  the  epithelial 
variety,  and  will  probably  be  seated  on  the  lip  or  in  the  rectum;  and  if  he  is 
seized  by  a  convulsion,  epileptic  or  otherwise,  the  idea  of  central  or  cerebro- 
spinal lesion  will  be  naturally  entertained. 

Both  sexes  furnish  examples  of  cardiac  derangement.  In  the  male,  they 
are  not  often  present  unless  some  structural  change  has  taken  place  in  the 
heart  and  bloodvessels,  such  as  valvular  disease,  atheroma,  or  aneurism  ; 
while  in  the  female,  they  are  quite  as  frequently  the  result  of  reflex  irritation. 
Hernia  is  met  with  in  both  sexes ;  but  while  inguinal  hernia  largely  outnum- 
bers all  other  varieties  in  the  male,  in  the  female  sex,  the  femoral  variety  is 
very  common.  AVhile,  however,  in  the  main,  the  portrait  which  has  been 
drawn  is  a  true  one,  yet  the  surgeon  must  never  assume,  without  a  most 
critical  and  exhaustive  investigation  having  first  been  made,  that,  because 
the  patient  is  a  woman,  certain  symptoms  have  no  real  or  substantial  basis. 
Indifference  to  this  caution  has  cost  many  women  their  lives,  the  disease 
having  been  unrecognized  until  too  late  to  admit  of  a  remedy. 

Occupation  is  not  only  a  fruitful  cause  of  disease,  but  determines  in  many 
instances  the  nature  of  the  morbid  process.  The  worker  in  a  manufactory 
of  lucifer  matches,  provided  that  a  defective  tooth  exists  in  the  jaw,  is  prone 
to  suffer  from  phosphor-necrosis  of  the  maxilla.  The  painter  becomes  the 
subject  of  lead  colic ;  the  chimney-sweep,  of  soot-cancer  of  the  scrotum. 
Persons  who  are  employed  in  the  manufacture  of  chemicals,  who  are  constantly 
exposed  to  contact  with  irrespirable  gases,  or  who  are  habitually  engaged  in 
sand-paper  and  glue  establishments,  not  infrequently  fall  victims  to  serious 
disease  of  the  air  passages  and  lungs.  The  house-maid,  some  of  whose  duties 
require  her  to  be  much  in  the  kneeling  posture,  is  liable  to  have  an  enlarge- 
ment of  the  patellar  bursa.  Plumbers  and  other  persons  whose  occupations 
call  them  to  labor  in  damp  or  wet  localities,  such  as  ditches,  drains,  etc., 
are  peculiarly  predisposed  to  rheumatism.  A  particular  occupation  or  trade 
may  produce  such  alterations  in  the  form  or  symmetry  of  the  body  as,  if 
not  understood,  would  be  apt  to  create  much  unnecessary  apprehension  in 
the  mind  of  the  surgeon.  Thus,  the  shoemaker  or  the  tailor,  toiling  day 
after  day  over  the  lap-stone  or  the  lap-board,  becomes  round-shouldered,  and 
finally  gets  a  curved  spine,  or  changes  the  form  of  Ins  breast;  while  the 
boy  who  is  constantly  engaged  at  the  lathe,  destroys,  by  the  habitual  use  of 
the  same  foot,  the  bilateral  symmetry  of  the  lower  extremities. 

Eabits. — The  influence  of  habit  not  only  constitutes  a  powerful  element  in 
the  production  of  many  of  the  affections  of  the  body  which  become  the  sub- 
jecta  of  medical  or  surgical  attention,  but,  when  recognized,  materially  modi- 
lies  prognosis,  and  explains  phenomena  which  otherwise  would  be  exceedingly 
obscure.  Thus  we  have  defects  of  vision  which  are  induced  by  the  excessive 
use  of  tobacco  ;  except  for  the  knowledge  of  the  existence  of  this  practice,  the 
appearances  of  the  eye  would  excite  serious  apprehension  for  its  future.     The 


GENERAL   EXAMINATION:    HISTORY    OF   THE    CASE.  341 

same  habit,  not  infrequently,  is  instrumental  in  producing  follicular  pharyn- 
gitis, but  the  prognosis  will  be  very  different  in  a  case  of  this  nature  arising 
from  smoking,  and  in  one  symptomatic  of  pulmonary  disease.  The  surgeon's 
opinion  in  regard  to  a  sore  on,  or  a  discharge  from,  the  male  or  female  geni- 
talia, will  be  influenced  in  no  small  degree  by  the  known  purity  or  depravity 
of  the  patient.  But,  on  the  other  hand,  a  chaste  and  virtuous  young  woman, 
or  an  innocent  wet-nurse,  may  suffer  unjustly  in  character,  the  one  having 
been  infected  by  an  impure  kiss  from  a  lover  whose  lip  bears  a  syphilitic 
crack,  and  the  other  by  suckling  a  syphilitic  child.  In  childhood,  a  prepuce 
elongated  by  habitual  traction  with  the  fingers,  at  once  excites  the  suspicion 
of  either  stone  in  the  bladder  or  the  existence  of  a  tight  phimosis.  Sexual 
weakness,  when  ascertained  to  be  the  result  of  venereal  excess,  assumes  a  very 
different  importance  from  that  which  it  possesses  when  induced  by  the  oxa- 
late of  lime  diathesis,  or  by  spinal  concussion. 

Antecedent  History. — This  embraces  a  history  not  only  of  the  past  life  of 
the  patient,  but  also  of  that  of  his  ancestors.  Nothing  is  better  established  than 
the  transmissibility  of  disease.  It  is  much  more  likely  to  abide  with  tlie 
children,  than  the  wealth  which  they  inherit.  Singularly  enough,  it  some- 
times happens  that  morbid  legacies  will  skip  a  generation  and  appear  in  the 
succeeding  one,  although  such  cannot  be  said  to  be  the  rule.  The  value  of  a 
knowledge  of  antecedents  in  imparting  certainty  to  diagnosis,  is  incalculable. 
A  patient  who  in  the  past  has  been  the  victim  of  syphilis,  and  who,  after 
probably  the  lapse  of  years,  is  attacked  with  pains  in  the  course  of  certain 
bones,  will  demand  a  different  kind  of  treatment  from  that  proper  to  a  case 
of  idiopathic  rheumatism  ;  and  the  same  will  be  true  of  an  iritis  arisino-  from 
a  similar  cause.  There  are  many  instances  of  persons  who  exhibit  symptoms 
of  pulmonary  disease,  but  in  whom  no  detectable  lesion  exists.  The  physi- 
cian may  be  in  doubt  as  to  the  necessity  of  a  change  of  climate,  but  if  it  be 
shown  that  a  maternal  or  paternal  ancestor  has  "died  of  tuberculosis,  that 
doubt  will  be  immediately  solved  and  the  change  advised.  A  pain  in  the 
knee  or  in  any  other  articulation  of  a  child,  awakens  much  more  anxiety  when 
it  is  known  that  there  is  an  antecedent  history  of  tubercular  disease ;  and  so 
in  the  clinical  investigation  of  obscure  tumors,  the  diagnosis  is  influenced  in 
no  small  degree  by  what  can  be  learned  with  regard  to  the  physical  sound- 
ness or  unsoundness  of  ancestors  and  other  relatives. 

Personal  History  is  no  less  important  than  a  history  of  antecedents  in 
interpreting  morbid  phenomena.  In  this  is  comprised  acknowledge  of  con- 
stitutional peculiarities.  An  individual  possessed  of  a  sanguine  temperament, 
as  manifested  by  the  possession  of  a  strong  and  vigorous  heart,  a  full  and 
bounding  pulse,  a  florid  complexion,  a  warm  surface,  and  the  other  signs  of  a 
dominating  vascular  system,  is  one  predisposed  to  acute  inflammation  of 
different  organs.  Apprised  of  such  a  constitutional  predisposition,  the  sur- 
geon will  be  ever  on  the  alert,  anticipating  these  complications,  and  pre} tared 
to  combat  them  before  they  have  gained  strength  or  have  become  fully 
entrenched.  The  patient  may  possess  a  phlegmatic  temperament,  character- 
ized by  a  dark  complexion,  a  lazy  circulation,  and  obtuse  sensibility,  with 
the  mental  operations  and  bodily  movements  alike  conducted  sluggishly. 
Individuals  so  constituted  are  stolid,  indifferent  to  suffering,  and  disposed  to 
endure  quietly  rather  than  complain  by  word  or  other  demonstration.  Here 
the  tendency,  on  the  part  of  the  medical  attendant,  is  to  undervalue  the 
power  or  severity  of  the  disease  or  injury,  and  to  be  betrayed  into  a  false 
sense  of  security  while  the  mischief  is  underrated  or  is  not  detected  until  too 
late  for  successful  management.     Allowance  must  also  be  made  for  persons 


342  GENERAL    PRINCIPLES   OF   SURGICAL   DIAGNOSIS. 

of  a  nervous  temperament,  those  restless  individuals  with  quick  movements, 
whose  circulation  is  easily  excited,  and  who  endure  pain  badly.  Their  excessive 
sensibility  and  easily  extorted  complaints  must  be  largely  discounted. 

There  is  another  aspect  in  which  personal,  antecedent  history  should  be 
considered,  and  which  must  influence  diagnosis.  Thus  if  a  joint  should  suddenly 
become  swollen  and  painful,  the  disorder,  aside  from  any  previous  history, 
might  be  attributed  to  very  different  causes;  but  if  it  were  ascertained  that, 
immediately  before  the  occurrence  of  the  trouble,  the  patient  had  met  with  a 
fall  or  a  violent  wrench  of  the  limb,  all  the  phenomena  would  be  referred  to 
a  sprain.  If  it  should  be  known  that  an  attack  of  epilepsy  had  been  pre- 
ceded, at  some  interval,  by  violence  applied  to  the  head,  it  would  not  only  be 
logical  to  refer  the  convulsion  to  a  traumatic  origin,  but  a  knowledge  of  the 
fact  would  be  of  the  utmost  value  in  determining  the  propriety  of  operation. 
In  a  case  of  facial  paralysis,  both  the  diagnosis  and  the  prognosis  would 
be  modified  by  learning  that  the  loss  of  power  had  followed  a  blow  below 
the  ear.  A  person  picked  up  in  a  state  of  coma,  and  with  the  smell  of  liquor 
on  his  breath,  might  be  subjected  to  a  damaging  and  unjust  criticism;  one 
which  would  be  quickly  recalled  if  it  should  afterwards  appear  that  the 
patient  had  fallen  or  been  precipitated  headlong  from  his  carriage  or  his  horse. 
In  certain  cases  of  convulsions  resembling  those  of  tetanus,  hysteria,  or  mania, 
how  much  light  is  shed  on  the  disease,  when  it  is  known  that  the  patient  has 
been  bitten  by  a  rabid  dog!  Xot  infrequently  information  on  some  of  the 
above  conditions  can  only  be  obtained  from  some  person  other  than  the  patient 
himself. 

Mental  and  Moral  States. — The  influence  of  the  mind  and  emotions 
over  the  functions  of  the  body,  is  perhaps  too  often  under-estimated.  Such 
influences  are  notably  concerned  in  causing  disturbances  of  the  various  secre- 
tions. Under  the  feeling  of  fear,  the  action  of  the  salivary  and  other  glands 
of  the  mouth  and  pharynx  may  be  for  a  time  entirely  suspended,  and  the  throat 
rendered  so  dry  that  nothing  solid  can  be  swallowed.  A  marked  suppression 
of  urine  will  occasionally  occur  as  a  result  of  great  mental  anxiety  or  distress. 
Profound  grief,  which  no  formula  of  words  can  express,  is  often  denied  the 
relief  of  tears,  from  the  operation  of  the  lachrymal  glands  being  completely 
arrested.  The  harass  and  worry  of  business  cares  will  sometimes  beget  an 
irritable  bladder.  Permanent  impotence  has  been  produced  by  fright.  The 
shock  following  the  communication  of  unwelcome  tidings  has  developed  a 
heart  murmur;  and  the  effects  of  fear,  of  remorse,  or  of  disappointment  from 
the  miscarriage  of  cherished  plans  at  the  moment  of  their  expected  consumma- 
tion, are  always  unfavorable  to  the  reparation  of  surgical  injuries.  Then  there 
is  an  anient  temperament,  which,  when  associated  with  a  highly  wrought 
imagination,  tends  to  impart  an  unreal  or  fictitious  coloring  to  the  disease  or 
injury  of  its  possessor,  and  is  well  calculated  to  mislead  the  unsuspecting  prac- 
titioner. Hope  is  a  mighty  element  in  the  cure  of  disease,  and  it  is  the  duty 
of  the  surgeon,  whenever  he  can  conscientiously  do  so,  to  avail  himself  of  this 
powerful  cordial  and  stimulus,  which  constitutes  so  efficient  an  antidote  to  the 
effects  of  sickness  and  injury. 

Social  Condition. — This  will  also  become  a  subject  of  investigation,  which 
should  include  an  inquiry  into  the  state  of  the  patient,  whether  single  or  mar- 
ried, active  or  idle;  his  sexual  indulgences,  whether  occasional  or  frequent, 

lawful  or  illicit ;  and,  in  the  case  of  a  woman,  the  number  of  her  pregnancies, 
of  her  miscarriages,  and  of  any  irregularities  or  complications  which  may 
have  taken  place  during  or  after  parturition. 


KNOWLEDGE   OBTAINED   BY   PERSONAL   INVESTIGATION.  343 

Residence. — The  influence  of  local  conditions  in  affecting  surgical  diseases 
must  not  be  overlooked.  Miasma  contracted  during- a  temporary  residence 
in  some  unhealthy  distrk-t,  will  often  lie  dormant  in  the  system  until  aroused 
into  activity  when  the  individual  is  overtaken  by  some  accident.  It  is, 
accordingly,  a  great  relief  to  the  mind  of  the  surgeon,  if,  on  the  occurrence 
of  a  rigor  after  an  operation  or  injury,  it  be  ascertained  that  the  patient  has 
previously  been  exposed  to  malarial  inliuences.  The  effect  of  location  in 
impressing  certain  characters  on  disease  is  well  seen  in  the  nature  of  many  of 
the  maladies  which  befall  large  'numbers  of  our  metropolitan  populations, 
whose  residences,  situated  in  lanes  and  alleys,  are  often  damp  and  badly  sup- 
plied with  either  sunlight  or  air,  and  who  subsist  on  food  the  quality  and 
preparation  of  which  render  it  unsuited  to  the  purposes  of  nutrition.  The 
propriety  of  referring  to  the  effect  of  residence,  the  ophthalmic,  glandular, 
and  other  diseases  incident  to  defective  nutrition  which  are  usually  encoun- 
tered in  persons  living  in  such  dwellings  and  under  such  surroundings,  will 
be  apparent. 

Duration  of  Disease. — The  period  over  which  a  disease  extends,  has  no 
small  influence  in  determining  the  question  of  its  nature.  Thus,  as  regards 
morbid  growths,  a  tumor  which  has  existed  for  several  years  without  causing 
any  marked  uneasiness,  either  local  or  general,  will  probably  be  regarded  as 
benignant,  while  one  of  a  few  months'  duration,  which  has  rapidly  Increased 
in  size,  will  be  deemed  malignant.  There  are,  of  course,  some  exceptions  to 
this  rule. 

Special  Examination:  Knowledge  Obtained  by  Personal  Investigation. 

Posture  or  Attitude. — The  eye,  when  educated  in  the  school  of  experi- 
ence, will  often  be  able  to  detect  the  nature  of  a  disease  in  the  posture  assumed 
by  the  patient.  Incipient  coxalgia  is  disclosed  in  a  Hexed  position  of  the  limb, 
in  eversion  of  the  foot,  and  in  obliteration  of  the  gluteo-femoral  groove  ; 
dislocation  of  the  head  of  the  femur  on  the  dorsum  ilii  will  be  recognized 
by  the  shortening  of  the  limb,  by  inversion  of  the  foot,  and  by  the  salient 
position  of  the  trochanter  major  ;  while  in  intracapsular  fracture  of  the  thigh 
bone,  the  nature  of  the  accident  will  be  strongly  suspected  on  seeing  the  foot 
lie  on  its  outer  side.  In  acute  peritonitis,  the  inflammation  is  revealed  by 
the  dorsal  decubitus,  flexed  limbs,  and  distended  belly ;  while  in  colic,  or 
spasm  of  the  muscular  walls  of  the  intestines,  the  patient  will  often  lie  on 
the  abdomen.  A  child,  who,  in  walking,  keeps  the  body  rigidly  straight 
and  stiff  (Fig.  21),  the  shoulders  elevated  and  the  arms  abducted,  and  who  moves 
with  a  shuffling  gait,  furnishes  the  evidence  of  spinal  caries;  as  he  does 
also  when  he  squats  down  instead  of  bending  in  order  to  pick  up  an  object 
from  the  ground  (Fig.  22).  A  large,  inflammatory  effusion  into  the  thorax 
or  into  the  abdomen,  generally  necessitates  a  sitting  instead  of  a  recum- 
bent posture.  A  patient  who  carries  an  uninjured  arm  flexed  and  sup- 
ported by  the  opposite  hand,  with  the  head  inclined  to  the  damaged  side,  will 
probably  be  found  to  have  a  broken  clavicle.  Sliding  down  in  the  bed  be- 
tokens extreme  exhaustion.  "In  all  cases  in  which  persons  are  seen  to  fix  the 
shoulders,  either  by  resting  the  hands  on  the  bed  or  by  throwing  an  arm  over 
the  back  of  a  chair,  or  any  unyielding  support,  difficulty  of  respiration  may 
be  safely  predicated.  Indeed,  almost  every  disease  and  injury  will  betray,  to 
some  extent,  its  nature  in  the  posture  assumed  by  the  patient. 

External  Expressions  of  Parts. — A  correct  knowledge  of  the  normal 
appearance  or  form  of  different  parts  of  the  body,  is  of  inestimable  value  to 


344 


GENERAL    PRINCIPLES    OF    SURGICAL    DIAGNOSIS. 


the  physician  or  the  surgeon,  as  it  is  only  by  the  possession  of  such  knowledge 
that  he  is  able  to  appreciate  those  deviations  which  are  produced  by  disease 
or  accident.  A  flattened  shoulder,  with  a  salient  acromion  process,"  suggests 
a  luxation  of  the  humerus ;  a  prominence  of  the  spinous  processes  of  one  or 


Fig.  21. 


Fig.  22. 


Appearance  of  child  suffering  from  caries  of 
the  vertebrae. 


Mode  of  stooping  in  a  subject  of  spinal  caries. 


more  vertebras,  indicates  the  existence  of  Pott's  disease  of  the  spine ;  the 
obliteration  of  the  gluteo-femoral  fold  raises  a  suspicion  of  coxalgia  ;  angular 
deformity  in  the  continuity  of  a  limb  reveals  a  fracture  of  its  bone  or  bones ; 
a  joint,  whose  surface  depressions  and  elevations  have  all  been  merged  in  a 
general  swelling,  is  likely  to  be  tilled  with  fluid ;  and  the  obliteration  of  the 
intercostal  depressions,  by  the  bulging  of  the  tissues  between  the  ribs,  indi- 
cates an  empyema  or  hydrothorax.  The  form  or  shape  of  a  swelling  will 
often  reveal  its  exact  location.  Thus,  an  enlargement  situated  under  the  jaw, 
the  Limitations  of  which  are  the  angle  of  the  inferior  maxilla  posteriorly, 
the  symphysis  of  the  jaw  anteriorly,  and  the  digastric  muscle  below,  will  be 
found  1<>  be  seated  in  the  submaxillary  region  ;  and  in  like  manner,  a-  swelling 
which  is  rigidly  confined  between  the  spine  of  the  scapula  and  the  upper 
border  of  the  hone,  will  in  all  probability  lie  beneath  the  deep  fascia  and  in 
the  supraspinous  fossa.  As  other  illustrations  under  this  head,  may  be  men- 
tioned the  acuminated  form  of  an  abscess,  the  pyriform  scrotum  in  hydrocele, 
the  convoluted  appearance  of  varicocele,  the  frown  which  settles  on  the  brows 
in  peritonitis  from  the  contraction  of  the  corrugator  muscle,  the  sardonic 
grin  in  tetanus,  the  pinched  features  of  the  Hippocratic  face,  presaging  ap- 
proaching dissolution,  and  the  notched  teeth  in  transmitted  syphilis,  with 
many  others  which  might  be  readily  adduced. 


KNOWLEDGE    OBTAINED    BY    PERSONAL    INVESTIGATION.  3-15 

Information  Derived  from  Touch. — While  in  most  instances  the  form  of  a 
swelling  can  be  determined  by  the  eye  alone,  yet  occasionally  it  becomes 
necessary  to  call  into  requisition  the  sense  of  touch,  in  order  to  obtain  a  cor- 
rect idea  of  the  exterior  of  an  enlargement.  Thus  a  tumor  within  the  abdo- 
men, or  in  the  neck,  or  in  the  groin,  may  present  a  uniform  surface  to  the 
eye,  but,  when  examined  by  the  fingers,  may  be  found  to  be  irregular  or  lobu- 
lated.  It  is  possible,  in  some  cases  of  extra-uterine  pregnancy,  to  trace  the 
outline  of  the  fetus  through  the  abdominal  walls  or  through  the  vagina,  and 
thus  to  establish  the  diagnosis.  In  this  way,  also,  the  convoluted  form  of  a 
varicocele,  and  the  irregularity  or  knobbed  surface  of  a  mammary  tumor,  will 
be  disclosed.  The  lenticular  form  of  the  inguinal  glands,  discoverable  by  the 
touch,  serves  to  distinguish  an  adenitis  from  a  hernia. 

Independent  of  the  external  configuration,  we  learn,  from  the  touch,  the 
density  of  tumors  and  other  enlargements — whether  liquid  or  solid,  hard  or 
soft,  elastic  or  doughy,  fluctuating  or  tremulous.  By  tact,  also,  we  recognize 
the  peculiar  crepitation  or  crackling  which  indicates  a  collection  of  air  in  the 
subcutaneous  connective  tissue  (emphysema).  By  the  same  sense,  the  crepitus 
of  fractures  and  the  crackling  of  inflamed  bursas  can  often  be  distinguished 
when  their  sound  cannot  be  heard ;  and  it  is  through  the  touch  that  the 
physician  measures  the  force,  frequency,  and  regularity  of  the  arterial  pulse. 

"Weight. — Closely  related  to  the  exercise  of  touch  is  the  estimation  of 
weight.  The  diagnosis  of  a  tumor  is  influenced  in  no  small  decree  by  its 
weight.  Disproportion  between  the  weight  and  the  bulk  of  a  morbid  growth 
located  in  the  testis  or  mammary  gland,  affords  considerable  ground  for  re- 
garding the  neoplasm  as  either  a  carcinoma  or  a  fibroma. 

Mobility  is  also  determined  by  an  exertion  of  the  sense  of  touch.  External 
growths  which  admit  of  being  extensively  moved  are  usually  superficial ; 
.while  those  which  are  fixed  are,  as  a  rule,  deeply  situated.  In  fracture  there 
is  preternatural  mobility,  while  in  luxation  there  is  unnatural  rigidity. 

Temperature,  although  only  to  be  correctly  measured  by  thermometry, 
may  often  be  estimated  by  the  touch  with  sufficient  accuracy  to  enable  the 
practitioner  not  only  to  form  just  deductions  in  regard  to  the  nature  of  the 
disease,  but  to  prescribe  the  proper  line  of  treatment. 

Too  much  attention  cannot  be  bestowed  on  the  cultivation  of  the  sense  of 
touch.  It  is  susceptible  of  being  educated  to  a  degree  of  extreme  delicacy, 
as  is  witnessed  in  the  readiness  with  which,  in  the  blind,  it  is  made  to  sup- 
plement the  deficiencies  of  vision.  Many  fatal  blunders  in  surgery  have 
resulted  from  an  untrustworthy  touch. 

Color,  also,  is  to  be  considered  in  forming  a  diagnosis.  Thus  we  have  the 
bright  scarlet  blush  which  belongs  to  acute  inflammation  ;  the  dusky  red 
which  accompanies  low  forms  of  erysipelas  ;  the  dull  red  or  mottled  hue  of 
chronic  inflammation,  indicating  also  venous  obstruction ;  the  blue  or  livid 
color  of  the  lips  in  some  cases  of  croup,  or  in  asphyxia ;  and  the  purple  and 
red  intermingled  which  mark  the  skin  overlying  malignant  growths.  To 
these  may  be  added  the  varying  shades  of  color — blue,  blue-black,  olive,  and 
yellow— which  follow  ecchymoses  or  extravasations  of  blood,  generally 
venous,  into  the  subcutaneous  cellular  tissues  ;  the  black  of  mortification ; 
the^  unnatural  white  of  anasarca ;  and,  finally,  the  sallow  and  waxy  hues 
which  attend  advanced  cases  of  carcinoma. 

Translucency. — The  true  nature  of  many  swellings  is  ascertained  by  the 
translucency  of  their  contents.    The  existence  of  this  condition  is  revealed  by 


346  GENERAL   PRINCIPLES   OF   SURGICAL   DIAGNOSIS. 

placing  the  patient  in  a  darkened  chamber,  and  by  supporting  the  part  to  be 
examined  between  the  surgeon  and  a  lighted  taper  or  candle,  the  hand  at  the 
same  time  being  placed  vertically  above  the  tumor  in  order  to  intercept  the 
upper  rays  of  light,  which  otherwise  would  confuse  the  vision.  A  less  satis- 
factory mode  of  demonstrating  translueency,  which  may  be  practised  by  sun- 
light, consists  in  using  a  hollow  cylinder  of  paper,  one  end  of  which  is  placed 
on  the  swelling  while  the  eye  of  the  surgeon  is  applied  at  the  other  end.  It 
is  in  this  way  that,  either  by  artificial  illumination  or  by  sunlight,  we  are 
enabled  to  recognize  a  hydrocele,  a  spina  bifida,  and  various  forms  of  cyst. 

Mensuration. — The  measurement  of  parts  also  serves  to  enlighten  diag- 
nosis, the  standard  of  reference  being,  in  the  case  of  the  extremities,  the 
corresponding  sound  limb.  The  metallic  or  the  linen  tape-line,  accurately 
graduated,  is  best  adapted  for  obtaining  measurements.  In  cases  of  fracture 
and  of  dislocation,  a  resort  to  mensuration  is  often  necessary  before  any  reli- 
able conclusion  can  be  reached.  Much  care  is  required  to  render  this  mode 
of  investigation  valuable.  For  example,  in  applying  the  tape-line  to  the 
lower  extremities,  the  patient  should  be  laid  on  a  level,  unyielding  surface ; 
the  limbs  placed  side  by  side ;  and  the  bod}'  in  an  exact  line  with  the  ex- 
tremities, so  that  the  pelvis  shall  not  incline  to  the  right  or  to  the  left.  Any 
deviation  from  this  position  will  so  vitiate  the  measurements  as  to  render 
them  nugatory  and  unreliable.  It  is  also  necessary  that  the  measurements 
shall  be  made  between  points  of  the  skeleton  which  are  stable  and  unvary- 
ing ;  in  the  lower  extremities,  from  the  anterior  superior  spinous  process 
of  the  ilium  or  the  spine  of  the  pubic  bone  above,  to  the  internal  malleolus 
below ;  or,  in  case  of  dislocations  of  the  coxo-femoral  articulation,  from  the 
anterior  superior  spinous  process  of  the  ilium  to  the  trochanter  major  and  the 
tuberosity  of  the  ischium.  In  the  upper  extremity,  the  points  of  reference, 
in  fracture  of  the  humerus,  are  the  acromion  process  of  the  scapula  and  the 
condyles  of  the  humerus ;  and,  in  elbow  dislocations,  the  condyles  and  the 
olecranon  process  of  the  ulna. 

By  the  tape-line,  any  irregularity  between  the  two  sides  of  the  thorax, 
such  as  is  likely  to  occur  in  effusions  into  the  cavity  of  the  pleura,  can  be 
determined,  as  can  also  the  growth  of  an  ovarian  cyst  or  the  enlargement^  of 
a  dropsical  joint.  Deviations  of  form  from  the  perpendicular  can  be  easily 
determined  by  the  plumb-line.  When  it  is  desired  to  obtain  an  exact  trans- 
cript of  the  angles  or  curves  of  the  vertebral  column,  this  can  be  done  either 
by  laying  over  "the  spine  a  malleable  metallic  ribbon,  and  pressing  it  into  the 
irregularities,  or  by  running  up  and  down  the  vertebras  two  or  three  times 
a  wet  plaster-of-Paris  roller,  and,  after  it  hardens,  removing  it  from  the  back, 
when  it  will  be  found  to  retain  the  exact  shape  of  the  column. 

Sound. — Through  the  educated  ear,  the  physician  and  the  surgeon  discover 
pathological  conditions  which  are  going  on  in  parts  and  organs  far  out  of 
sight.  By  the  sense  of  hearing,  the  crepitation  of  a  pneumonia,  the  friction 
sound  of  a  pleurisy,  the  segophony  of  thoracic  effusions,  murmurs  attending 
defects  in  the  mitral  and  semilunar  valves  of  the  heart,  the  bruit  of  an  aneu- 
rism, the  fly-buzz  of  arterio-venous  aneurism,  the  click  elicited  by  the  contact 
of  a  sound  with  a  calculus,  and  the  crepitus  of  fracture,  can  all  be  ascertained. 

Movements. — These  may  bo  less  or  greater  than  normal,  or  they  may  be 
constrained,  or  eccentric.  Examples  of  diminished  mobility  are  seen  in  cases 
of  fractured  ribs,  or  of  collapsed  lung — where  the  walls  of  the  chest,  on  the 
injured  side,  become  almost  quiescent.  An  inflamed  joint  immediately  seeks 
rest,  and  a  broken  arm  or  leg  enforces  a  suspension  of  voluntary  muscular 


INTERROGATION  OF  THE  INTERNAL  ORGANS.  347 

movements.  Excessive,  or  exaggerated,  or  involuntary  movements  are  witnessed 
in  the  walls  of  the  chest  in  cases  of  difficult  breathing,  either  from  pulmonary 
or  cardiac  disease.  There  are  excessive  movements  which  attend  the  loss  of 
the  governing  or  inhibitory  power  of  the  nervous  system  which  regulates 
muscular  action,  as  is  seen  in  chorea,  paralysis  agitans,  nystagmus  or  oscillat- 
ing eyes,  epilepsy,  hysteria,  and  ataxia. 

Constrained  movements  often  reveal  serious  structural  disease.  Incipient 
spinal  caries  may  be  detected  by  the  mechanical,  cautious,  and  shuffling  walk 
of  the  child,  before  any  external  deformity  can  be  noticed.  Eccentric  mover 
meats  are  seen  in  cases  of  infantile  paralysis,  in  which  the  loss  of  power  in  the 
extensors  of  the  thigh  compels  the  child  to  advance  the  limb  by  the  action 
of  the  muscles  placed  on  the  outer  aspect  of  the  pelvis,  in  doing  which  the 
extremity  is  swung  around  in  the  segment  of  a  circle,  instead  of  being  car- 
ried directly  forward. 

Smell. — The  sense  of  olfaction  is  as  quick  to  appreciate  odors  of  an  un- 
pleasant as  of  a  pleasant  nature.  In  this  way  dissolution  of  the  tissues, 
necrosis  of  bone,  steivoraeeous  fistula,  nasal  catarrh,  or  incontinence  of  urine 
can  be  detected.  The  odor  of  hay,  which  often  attends  pyeemia,  can  frequently 
be  so  distinctly  recognized,  as  to  cause  suspicion  of  the  existence  of  this  dis- 
ease, before  anything  is  known  about  the  history  of  the  case.  There  is,  also, 
a  peculiar,  earthy  smell,  which  belongs  to  the  soft  parts  when  undergoing 
mortification,  and  which  is  detectable  by  the  olfactories,  in  many  instances, 
in  advance  of  the  exposure  of  the  diseased  tissues.  As  a  final  illustration 
under  this  head,  I  may  mention  the  offensive  odor  discoverable  on  inhaling 
the  breath  of  a  patient  laboring  under  obstruction  of  the  follicles  of  the  ton- 
sils, an  odor  which  results  from  the  decomposition  of  the  retained  secretion. 


Interrogation  of  the  Internal  Organs. 

In  order  to  make  a  diagnosis  thorough,  the  condition  of  the  internal  organs 
must  be  ascertained.  This  will  include  an  examination  of  the  organs  of 
circulation,  respiration,  and  digestion,  as  well  as  of  those  of  the  genito-urinary 
apparatus  and  the  nervous  system. 

Circulation. — Under  this  head,  the  attention  of  the  practitioner  will  be 
directed  to  the  state  of  the  heart  and  of  the  bloodvessels,  noting  the  strength, 
regularity  of  beat,  and  sounds  of  the  former,  all  of  which  exercise  no  small 
influence  in  enabling  the  surgeon  to  decide  as  to  the  propriety  of  severe  and 
tedious  operations,  and  especially  as  to  the  administration  of  anaesthetics. 
When  the  inquiry  extends  to  the  bloodvessels,  the  relation  of  atheroma  to 
aneurism,  and  to  senile  gangrene,  must  be  considered,  as  must  also  the  pres- 
ence of  a  varicose  condition  of  the  surface  veins  of  the  chest  and  abdomen, 
indicative  of  obstruction  in  the  deep-seated  venous  trunks  of  those  cavities; 
the  pulsation  of  the  jugular  veins  in  anaemia;  and  the  relation  between  phle- 
bitis and  embolism,  and  between  varicose  veins  of  the  lower  extremities  and 
leg  ulcers.  In  like  maimer,  lividity  of  the  surface  is  important,  as  revealing 
defective  aeration  of  the  blood  from  obstructive  causes  or  from  cardiac  disease. 

The  state  of  the  circulation  is  usually  determined  by  the  pulse,  and  while 
the  fingers  rest  on  the  artery,  there  should  be  observed  the  force  of  its  beat, 
its  regularity,  its  volume,  and  its  compressibility.  The  influence  of  emo- 
tional causes,  of  age,  and  of  sex,  on  the  frequency  of  the  pulse,  must  be  noted. 
In  the  case  of  a  person  laboring  under  temporary  excitement,  or  in  that  of  a 
nervous  woman,  agitated  perhaps  by  the  visit  of  the  surgeon,  the  pulse  will 


348 


GENERAL   PRINCIPLES    OF   SURGICAL    DIAGNOSIS. 


often  vary  as  many  as  twenty  or  thirty  beats  in  as  many  minutes.  Even  per- 
sons in  health  present  variations  in  the  rapidity  of  the  circulation  at  different 
times ;  and  in  women  and  children,  the  pulse  is  always  more  rapid  than  in 
men  or  in  persons  advanced  in  life.  In  view  of  the  above  peculiarities,  the 
medical  attendant  who  is  familiar  with  the  details  of  his  profession,  generally 
asks  some  preliminary  or  general  questions,  in  order  to  place  his  patient  at 
ease  before  proceeding  formally  to  examine  the  state  of  the  circulation.  As 
a  rule,  in  all  inflammations  seated  below  the  diaphragm — for  example  in  pe- 
ritonitis and  enteritis — the  pulse  is  bard,  contracted,  and  cord-like;  whilst  in 
those  which  are  supra-diaphragmatic,  it  is  full  and  bounding.  In  compression 
of  the  brain,  the  beat  of  the  artery  is  slow,  full,  and  labored,  while  in  concus- 
sion, it-  is  frequent,  small,  and  feeble.  In  both  of  these  conditions,  a  gradually 
increasing  rapidity  of  the  pulse  presages  a  fatal  termination.  Gastric  distur- 
bance through  reflex  agency,  and  cardiac  disease  from  mechanical  disability, 
will  often  give  rise  to  an  irregular,  an  intermittent,  or  a  dicrotic  pulse.  Pro- 
fuse hemorrhage  imparts  to  the  arteries  a  peculiar,  gaseous  feel,  with  a  tremu- 
lous and  jerking  movement.  In  grave  injuries  of  the  extremities,  the  absence 
of  pulsation  in  the  principal  vessels  of  the  part  determines  the  question  of 
amputation. 

Thermometry. — The  relation  which  subsists  between  circulation,  tissue  me- 
tamorphosis, and  the  resulting  evolution  of  heat,  has  rendered  the  use  of  the 
thermometer  a  valuable  adjuvant  both  in  diagnosis  and  prognosis.  The  nor- 
mal temperature  of  the  body  lies  somewhere  between  98°  and  99°  Fahrenheit. 

Before  1636,  Sanctorius  had  drawn  the  attention 
Fig.  23.  Fig.  2'4.  of  the  profession  to  the  importance  of  thermometri- 

cal  observations  as  an  index  of  morbid  changes  in 
the  system ;  yet  the  first  experiments,  made  to  ascer- 
tain the  local  temperature  of  an  inflamed  part,  were 
those  of  John  Hunter  in  a  case  of  hydrocele.  The 
instrument  used,  however,  was  the  ordinary  ther- 
mometer, and  was  consequently  badly  adapted  for 
obtaining  accurate  results.  Two  forms  of  clinical 
thermometer,  of  which  the  first  is  the  best,  are 
illustrated  in  Figs.  23  and  24.  Another  excellent 
form  is  shown  in  Fig.  96,  page  527.  When  used, 
the  instrument  should  be  placed  either  under  the 
tongue  or  in  the  axilla.  If  in  the  latter  region, 
the  thermometer  should  be  retained  in  position  by 
placing  the  arm  close  to  the  side,  and  should  be 
allowed  to  remain  about  ten  minutes,  when  the 
mercury  will  have  risen  to  the  highest  point  it  is 
likely  to  reach.  It  is  customary  to  take  two  ob- 
servations each  day;  one  about  eight  o'clock  in 
the  morning  and  the  other  at  seven  o'clock  in  the 
evening.  These  should  be  recorded  upon  a  tem- 
perature sheet  kept  for  the  occasion,  and  placed 
either  at  the  head  of  the  bed  or  in  some  convenient 
place  for  reference. 

Between  the  elevation  of  temperature  and  the 
frequency  of  the  pulse,  there  is  some  general  cor- 
respondence; that  is  to  say,  for  every  degree  of 
heat  above  98 Q  Fahr.,  there  are  about  ten  pulsa- 
tions of  the  heart  more  than  when  that  organ  is 
Clinical  thermometers.  beating  with  its  normal  frequency.     Every  degree 


INTERROGATION  OF  THE  INTERNAL  ORGANS.  349 

above  the  normal  temperature,  is  an  evidence  of  increased  tissue  metamor- 
phosis, and  when  the  thermometer  records  105°  or  106°  Fahr.,  the  danger  to 
life  becomes  imminent.  In  fatal  cases  of  disease  or  injury,  the  temperature 
rapidly  falls  on  the  approach  of  death ;  an  occasional  exception  to  this  is 
sometimes  witnessed,  however,  in  instances  of  fatal  injury  of  the  head  or 
spinal  column. 

Respiration. — The  function  of  respiration  may  be  disturbed  from  mechan- 
ical, from  pathological,  or  from  emotional  causes,  and  the  phenomena  to  be 
observed  are  the  frequency,  the  ease,  and  the  regularity  with  which  the  pro- 
cess of  breathing  is  executed.  Mechanical  interruption  of  respiration  may 
be  caused  by  a  tumor  pressing  on  the  trachea,  by  the  presence  of  membranous 
formations  in  the  larynx  or  windpipe,  by  tumors  in  the  vicinity  of  the  rima 
glottidis,  or  by  foreign  bodies  within  the  oesophagus.  In  like  manner  hydro- 
thorax,  empyema,  and  pneumothorax,  by  pressing  the  lung  back  towards  the 
spine,  will  give  rise  to  difficult  and  labored  breathing.  In  pneumonia,  the 
inflammatory  infiltration  which  floods  the  parenchyma  of  the  pulmonary 
tissue,  not  only  presses  the  air  out  of  the  air-cells,  but  also  prevents  their  ex- 
pansion. This  necessitates  abnormally  frequent  respiratory  acts,  the  lung 
attempting  in  this  way  to  compensate  for  the  deficient  aeration,  incident  to 
imperfect  expansion.  Tubercular  infiltration  produces  similar  phenomena. 
Cardiac  disease  will  also  induce  hurried  breathing,  especially  when  the  patient 
is  compelled  to  walk,  to  climb  an  ascent,  or,  sometimes,  even  to  change  his 
position,  the  muscular  efforts  acting  as  a  stimulus  to  the  organ.  The  respiration 
may  be  slowed  or  quickened  by  disease  of  the  medulla  oblongata.  The  latter 
frequently  suffers  in  cases  where,  in  consequence  of  organic  changes  in  the 
kidneys,  these  organs  are  unable  to  eliminate  the  redundant  products  of  tissue 
waste,  wlun  their  retention  in  the  system  soon  begins  to  exert  its  toxic  effects 
on  the  brain  and  other  organs  of  the  body.  Blood  thus  loaded  with  meta- 
morphosed tissue  becomes  an  anesthetic  to  the  nerve-centres,  producing  stupor, 
with  labored  breathing,  which  may  alternate  with  excitement  and  rapid  respi- 
ration when  the  organs  begin  to  feel  an  urgent  need  for  better  blood.  The 
sluggish  flow  of  the  blood  through  vessels  which  have  undergone  atheroma- 
tous degeneration,  will  also  explain  similar  phenomena  so  often  witnessed  in 
persons  thus  affected.  In  many  instances,  the  two  acts  of  respiration,  inspi- 
ration and  expiration,  are  not  equally  involved ;  thus  in  croup,  in  oedema  of 
the  larynx,  and  in  certain  cases  of  laryngeal  tumor,  the  inspiration  is  most 
embarrassed. 

There  is  a  singular  power  of  compensation  resident  in  the  human  body, 
which  under  extraordinary  conditions  is  exhibited  in  a  very  striking  manner : 
thus  when  a  rib  is  broken,  in  order  that  the  process  of  repair  may  not  be  dis- 
turbed, the  movements  of  the  corresponding  side  of  the  chest  are  greatly 
diminished,  while  the  deficiency  is  measurably  supplemented  by  the  dia- 
phragm and  the  muscles  of  the  abdomen.  In  pleuritis,  the  inspiration  is 
brought  to  a  sudden  check  before  the  full  expansion  of  the  thoracic  walls  has 
been  completed. 

There  are  significant  sounds  accompanying  the  respiration,  which  possess 
great  diagnostic  value.  For  example,  the  tremulous  voice,  which  accompa- 
nies extreme  weakness ;  the  hiccough,  so  often  connected  with  grave  disorders, 
or  following  upon  the  appearance  of  mortification;  the  grunting  respiration 
which  attends  caries  of  the  vertebras  ;  the  stridulous  sounds  caused  by  the  air 
passing  between  obstructions  in  the  respiratory  tube ;  the  obscure,  mumbling 
articulation  of  words  in  cases  of  inflammatory  swelling  in  the  faucial  and 
pharyngeal  parts;  the  whisper  or  aphonia  from  swelling  of  the  larynx  or 
paralysis  of  the  vocal  cords  ;  and  the  tracheal  rales  which  announce  the  near 


350 


GENERAL   PRINCIPLES   OF   SURGICAL   DIAGNOSIS. 


approach  of  death.  Emotional  disturbances  of  respiration  are  characterized 
by  full  inspirations  and  expirations,  following  each  other  sometimes  rapidly, 
then  more  slowly,  and  often  executed  in  a  jerking  or  tremulous  manner. 
There  must  also  be  mentioned  the  slow,  stertorous  and  puffing  respiration 
from  paralysis  of  the  faucial  and  buccinator  muscles,  the  result  of  cerebral 
compression. 

The  respiratory  movements  of  the  thorax  are  often  observed  with  a  view  to 
furnish  the  rational  signs  of  disease.  In  pleuritis,  any  attempt  at  taking  a 
full  breath  is  not  only  followed  by  acute  pain  in  the  side,  but  the  inspiratory 
act  itself  is  suddenly  arrested  by  the  suffering  induced.  The  same  test  will, 
in  fracture  of  the  ribs,  develop  crepitus,  which  may  be  either  felt  with  the 
hand  or  heard  with  the  ear,  applied  over  the  injured  region.  In  swellings 
suspected  to  be  hernise,  the  diagnosis  is  strengthened  by  noticing,  in  the 
tumor,  a  distinct  impulse  on  coughing. 

Nervous  System. — Much  valuable  information  may  be  gleaned  by  testing 
the  common  sensibility  of  the  skin,  mucous  membranes,  and  muscles.  For  the 
coarser  examination  of  the  cutaneous  sensibility,  an  ordinary  pin,  or  a  pair 
of  compasses  will  answer ;  but,  for  nicer  and  more  accurate  results,  the  a?sthe- 
siometer,  of  which  two  forms  are  shown  in  the  annexed  cuts  (Figs.  25  and  26), 
should  be  employed. 


Fig  25. 


Fig.  26. 


iEsthesiometera. 


This  instrument  has  a  length  of  four  inches,  divided  into  tenths.  The 
aeuteness  of  the  sensibility  is  determined  by  the  greater  or  less  nearness  at 
which  the  touch  of  the  two  points  can  be  recognized  as  separate  impressiors. 

The  presence  of  certain  morbid  poisons  circulating  in  the  blood,  among 
which  may  be  instanced  that  of  syphilis,  will  lessen  very  much  the  aeuteness 
of  sensibility  of  the  skin,  and  the  same  is  true  of  a  number  of  nerve-lesions 
which  are  followed  by  numbness.  The  sensibility  maybe  excessively  exalted 
(hypermstkesia),  so  much  so,  indeed,  that  the  gentlest  touch  with  a  feather  or 
the  finger  will  be  intolerable,  and  will  give  rise  to  signs  of  extraordinary  suf- 
fering. Hyperesthesia  is  among  the  common  phenomena  of  hysterical  joints 
;ni(l  of  mimicked  disease  of  the  spine.  The  qualities  of  sensibility,  or  its 
perversions,  are  seen  under  different  phases  ;  sometimes  as  burning,  an  evidence 
of  nerve-injury;  sometimes  as  itching,  as  in  poisoned '  wounds ;  sometimes 
described  as  a  feeling  like  that  of  ants  crawling  over  the  surface  (formication) ; 
or  of  nettles  bring  brough.1  in  contact  with  the  skin  (urtication) ;  or  of  a  current 
of  air  passing  over  the  affected  part.     Such  conditions  of  the  peripheral 


INTERROGATION  OF  THE  INTERNAL  ORGANS.  351 

nerves  may  be  due  to  reflex  impressions,  or  to  organic  changes  in  the  spinal 
cord,  or  other  ganglionic  masses  of  neurine. 

The  absence  of  certain  reflex  movements,  as  those  proceeding  from  tapping 
the  patellar  tendon,  the  tendo  Achillis,  or  the  cremaster  muscle  over  the 
spermatic  cord,  are  supposed  by  some  writers  to  indicate  serious  changes  in 
the  structure  of  the  spinal  marrow,  though  there  are  other  authorities  who 
attach  little  importance  to  such  tests. 

Significance  of  Pain. — It  is  frequently  found  to  be  the  case  that  parts 
which  in  their  normal  state  exhibit  little  sensibility,  become  exquisitely  sensi- 
tive when  inflamed.  The  entire  muscular  system  of  a  child  is  frequently 
thrown  into  violent  paroxysms  from  an  inflamed  gum,  which,  in  the  healthy 
condition,  is  quite  insensible.  Inflammation  of  the  hard,  callous  tissue  of  the 
heel,  so  admirably  constructed  to  endure  pressure,  occasions  intolerable  suffer- 
ing. Pain,  of  which  we  are  only  conscious  through  certain  impressions  trans- 
mitted along  special  tracts  of  the  medulla  spinalis  to  the  brain,  thus  pos- 
sesses diagnostic  value.     Pains  differ  in  quality,  location,  and  duration. 

(1)  Quality  of  Pain. — Shooting,  darting,  or  shuttle-like  pains  belong  to 
carcinoma;  burning  pains  to  injury  of  the  nerves  and  inflammation  of  the 
skin  ;  itching  pains  to  poisoned  wounds  ;  dull,  heavy  pains  to  rheumatism  ; 
gnawing  or  boring  pains  to  disease  of  the  bones;  throbbing  pains  to  inflam- 
matory transudations  occurring  in  and  beneath  dense  or  unyielding  struc- 
tures, as  in  whitlow  and  palmar  abscess  ;  and  sickening  pains  to  contusions  of 
the  testes. 

(2)  Location  of  Pain. — Disease  is  not  always  situated  at  the  point  where 
pain  is  experienced.  Pain  is  very  commonly  felt  at  the  knee,  in  coxalgia  ; 
at  the  extremity  of  the  urethra,  in  vesical  calculus  ;  along  the  ureters  or  down 
the  thighs,  in  renal  calculus ;  and  at  the  inferior  angle  of  the  scapula,  in 
inflammatory  disorders  of  the  liver.  Disease  at  the  root  of  the  fifth  pair  of 
nerves  will  excite  pain  in  the  jaw  and  face.  Many  serious  errors  have  been 
committed  in  locating  disease  by  the  misleading  influence  of  local  pain. 

(3)  Duration  or  Constancy  of  Pain. — Constant  pain  is  usually  inflammatory 
in  its  origin  ;  intermittent  pain,  neuralgic.  In  peritonitis,  the  extreme  sen- 
sibility or  pain  continues  without  abatement ;  in  colic,  it  is  paroxysmal ;  the 
pain  of  peritonitis  is  aggravated  by  pressure,  while  that  of  colic  is  relieved  by 
the  same  means.  Fixed  pain,  that  which  never  shifts  its  position  and  is  con- 
tinuous for  a  long  time,  even  though  not  severe,  should  never  be  treated  as  a 
light  matter.  Fugitive  pains  are  usually  rheumatic  or  neuralgic.  The  sud- 
den cessation  of  pain  in  an  inflamed  part  often  announces  the  commencement 
of  gangrene. 

The  importance  to  be  attached  to  pain  must  be  regulated  in  some  degree 
by  the  temperament  of  the  individual  suffering  it.  There  are  persons  whose 
nervous  system  and  whose  mental  and  emotional  natures  are  so  constructed, 
that  the  slightest  pain  is  followed  by  extravagant  or  exaggerated  manifesta- 
tions of  suffering ;  while  there  are  othei\s,  heavy  and  phlegmatic  in  their 
organization,  or  possessing  an  iron  will,  who  either  do  not  feel  pain  as  much 
as  others,  or  who  endure  it  with  singular  fortitude  and  stolidity. 

Motility. — Many  obscure  morbid  conditions  are  unravelled  by  studying 
the  behavior  of  the  muscles.  There  are  three  sources  from  which  eccentric 
phenomena  of  the  muscular  system  may  be  derived  :  (1)  the  cerebro-spinal 
centre  ;  (2)  the  nerves  which  supply  the  muscular  fasciculi ;  and  (3)  the  sar- 
cous  cells.  Among  the  most  common  morbid  disturbances  of  muscles  are 
loss  of  power,  tremors,  spasms,  twitch ings,  contractions,  choreic  movements, 
and  wasting  or  atrophy. 

Loss  of  power  may  affect  one  muscle  or  a  number  of  muscles;  one  or  both 


352  GENERAL    PRINCIPLES    OF    SURGICAL    DIAGNOSIS. 

extremities  ;  the  half  or  the  whole  of  the  body.  "When  half  of  the  body  is 
affected,  the  cause  is  usually  referable  to  the  brain.  When  a  single  extremity 
or  both  lower  extremities  are  paralyzed,  the  cause  is  to  be  sought  for  in  the 
spinal  marrow.  A  single  muscle  or  group  of  muscles  may  be  paralyzed  from 
mechanical  causes,  such  as  the  pressure  of  a  morbid  growth,  or  of  a  mass  of 
exuberant  callus.  The  nerve  force  may  be  suddenly  exhausted  by  overtaxing 
the  muscles,  and  this  exhaustion  may  be  followed  by  temporary  or  reflex 
paralysis.  Spasms  and  twitchings  of  the  muscles  may  be  excited  by  the 
mechanical  irritation  from  the  spicule  of  a  broken  bone.  Local  irritations 
frequently  provoke,  through  reflex  agency,  general  spasms  of  the  muscular 
system,  as  is  witnessed  in  the  convulsions  which  accompany  difficult  denti- 
tion, or  which  are  brought  on  by  a  tight  phimosis,  by  overloading  of  the 
stomach  with  crude  ingesta,  or  by  uterine  disease.  Permanent  contractions 
of  the  muscles  often  occur,  causing  deformities  of  the  limbs ;  a  class  of  cases 
exceedingly  unpromising,  as  the  contractions  depend  upon  structural  changes 
which  are  altogether  irremediable,  namely,  sclerosis  of  the  anterior  columns 
of  the  spinal  cord.  In  fracture  of  the  vertebra?,  the  particular  region  of  the 
spine  involved  is  ascertained  by  observing  which  muscles  are  rendered  help- 
less. 

Loss  of  power  is  also  a  result  of  fatty  metamorphosis  of  the  sarcous  sub- 
stance, rendering  its  cells  incapable  of  being  affected  by  nerve  force.  Those 
neuroses  which  arise  from  peripheral  causes,  are,  of  course,  most  amenable  to 
treatment,  as  the  cause  is  in  many  instances  a  removable  one.  In  these  affec- 
tions of  the  nervo-muscular  system,  the  use  of  the  faradic  and  galvanic  cur- 
rents becomes  necessary,  in  order  to  test  not  only  the  pathological  alterations 
of  the  muscles,  but  also  to  ascertain  where  the  defect  lies ;  that  is  to  say, 
whether  in  the  centre  of  power,  in  the  nerve  of  communication,  or  in  degene- 
rated fibre.     An  instrument  called  the  dynamometer  (Fig.  27)  is  employed 

Fig.  27. 


Dynamometer,    The  outer  scale  represents  kilogrammes,  and  the  inner  myriagrammes. 

to  measure  the  degree  of  power.  The  movements  of  the  pointer  on  the  dial- 
plate,  when  grasped  by  the  hand  of  the  patient,  indicate  the  force  exerted,  in 
kilogrammes,  while  the  stretching  of  the  spring  in  the  longitudinal  direction, 
by  an  arrangement  of  cords  and  rings,  indicates  the  force  of  the  lumbar 
muscles,  or  the  lifting  power,  in  myriagrammes. 

Digestive  Apparatus. — The  wide  range  of  sympathies  possessed  b}^  the 
digestive  organs  confers  upon  them  a  notable  distinction  in  the  production  of 
morbid  phenomena.  This  fact  is  no  matter  of  surprise  to  the  anatomist,  who 
is  familiar  with  the  rich  supply  of  nerves  derived  from  the  sympathetic,  and 
their  intimate  communication  with  those  of  the  cerebrospinal  system.  Many 
disorders  of  the  circulatory,  respiratory,  nervous,  and  gen ito-uri nary  organs, 
though  but  reflected  irritations  from  some  portion  of  the  intestinal  tract, 


INTERROGATION  OF  THE  INTERNAL  ORGANS.  353 

would,  if  their  origin  was  not  understood,  assume  the  gravest  significance  in 
the  mind  of  the  practitioner.  In  studying  the  bearings  of  this  division  of 
the  subject,  the  inquiry  should  commence  at  the  mouth,  and  pass  downward 
to  the  termination  of  the  intestinal  tube,  including  the  different  glandular 
organs  contained  in  the  abdominal  cavity. 

In  the  tumid,  fissured  and  pale  lip,  are  to  be  seen  the  indications  of  struma, 
and  of  anaemia  ;  in  the  soft,  spongy  and  bleeding  gum,  a  scorbutic  state  of 
the  blood,  or  the  constitutional  effects  of  mercury  or  of  phosphorus.  The 
inflamed  and  swollen  gum  satisfactorily  explains  the  fretfulness,  otalgia, 
startings  and  convulsions  of  the  infant.  The  constitutional  effects  of  silver, 
of  lead,  and  not  unfrequently  of  tubercular  disease,  are  shown  in  charaet er- 
istic lines  upon  the  gums. 

Among  the  multiform  manifestations  of  syphilis  are  the  notched  incisor 
teeth  of  the  permanent  set.  The  failure  of  a  tooth  to  appear  in  the  dental  arch, 
if  associated  with  enlargement  of  the  jaw,  suggests  the  probability  of  a  dental 
cyst ;  while  an  inflammatory  swelling  and  abscess  of  the  face  and  neck,  about 
the  angle  of  the  jaw  in  the  adult,  will  direct  the  attention  of  the  surgeon  to 
the  possible  eruption  of  a  wisdom  tooth. 

The  tongue  constitutes  an  important  index  of  both  general  and  local  dis- 
order. The  dry  tongue  is  a  common  attendant  of  febrile  excitement,  and  is 
the  result  of  arrested  secretion.  A  similar  appearance  of  the  organ  is  seen 
in  persons  who  sleep  with  the  mouth  open,  and  is  due  to  evaporation  of  the 
natural  moisture  of  the  part.  Habitual  dryness  of  the  tongue  from  this  cause 
should  lead  the  practitioner  to  examine  the  nasal  cavities  for  polypi  or  other 
morbid  growths.  A  dry  tongue  with  rigidly  prominent  papillae,  occurring 
in  the  course  of  traumatic  and  other  fevers,  is  always  a  source  of  anxiety  to 
the  watchful  physician.  The  dry,  red,  and  glazed  tongue  is  among  the  com- 
mon signs  of  gastro-intestinal  inflammation,  as  is  a  similar  condition  of  the 
fauces  and  pharynx.  In  anaemia  the  organ  is  pale,  flabby,  and  soft.  The 
tooting  which  encrusts  the  tongue  when  it  is  furred,  is  made  up  of  epithelial 
cells,  the  debris  of  the  various  secretions  of  the  mouth,  altered  blood-corpus- 
cles, etc.  A  thin  white  coat  is  an  evidence  of  debility,  and  demands  tonics. 
A  heavy  white  coat,  tinged  with  yellow,  implies  derangement  of  the  biliary 
function.  A  dark,  pasty  crust,  adhering  in  strips,  and  found  also  attached  to 
the  gums,  constituting  sordes,  reveals  blood  disorganization,  and  is  the  atten- 
dant of  low  forms  of  fever.  It  should  not  be  forgotten  that  a  catarrh  of  the 
throat  will  often  cause  a  coated  tongue,  when  the  alimentary  tract  in  all 
other  portions  is  not  implicated.  The  form  of  the  tongue  is  not  without 
diagnostic  significance.  In  intra-cranial  inflammations, "when  the  brain  is 
not  subjected  to  too  much  pressure  from  transudations,  the  organ  will  be 
narrow  and  pointed  ;  in  chronic  derangements  of  the  digestive  organs,  it  will 
become  broad,  fissured,  and  rounded  at  the  borders ;  and  in  inflammations 
of  the  respiratory  organs,  it  not  infrequently  is  seen  to  be  transversely  con- 
cave, from  depression  of  its  centre  and  corresponding  elevation  of  its  sides. 
The  motions  of  the  tongue  are  well  worthy  of  observation.  A  tremulous 
state  of  the  organ,  or  difficulty  in  its  protrusion,  frequently  witnessed  in  low 
fevers,  betokens  great  danger.  When  thrust  out  to  one  side,  there  is  probably 
a  brain-lesion  on  the  opposite  side.  Angeiomatous  growths  appear  occasionally 
on  the  tongue,  and  cause,  in  the  affected  part,  a  blue,  spongy  enlargement. 
Mucous  patches  on  the  tongue  disclose  constitutional  syphilis." 

The  saUingual  space,  where  the  openings  of  the  sublingual  and  submaxillary 
salivary  ducts  exist,  should  not  escape  inspection.  Tumors  occurring  in  this 
region  are  likely  to  be  either  ranulae  or  salivary  calculi. 

Difficult  deglutition,  imperfect  or  guttural  enunciation,  cough,  and  stiff- 
ness of  the  neck,  will  demand  a  critical  examination  of  the  fauces  and  pha~ 
vol.  i. — 23 


354  GENERAL   PRINCIPLES   OF   SURGICAL   DIAGNOSIS. 

rynx — observing  if  there  exist  any  elongation  of  the  uvula,  any  hypertrophy 
of  the  tonsils,  any  enlargement  of  the  pharyngeal  glands,  any  post-palatine 
purulent  secretion,  or  any  swelling  in  front  of  the  cervical  vertebrae,  the  loca- 
tion of  post-pharyngeal  abscess  from  diseased  bone.  Inability  to  swallow 
solids,  with  return  of  the  alimentary  bolus,  demands  exploration  of  the 
oesophagus  with  appropriate  bougies  for  the  detection  of  stricture. 

Vomiting,  when  there  has  been  a  history  of  chronic  dyspepsia,  accompanied 
by  loss  of  flesh,  will  suggest  a  careful  examination  of  the  abdomen  for  inter- 
nal carcinoma.  Sudden  attacks  of  vomiting,  with  pain  and  flatulence,  attract 
the  attention  of  the  surgeon  to  the  hernial  passages.  The  appearance  and 
the  odor  of  the  ejected  matters  must  not  escape  observation,  stercoraceous 
emesis  always  denoting  intestinal  obstruction  from  some  cause. 

In  determining  the  outline  of  the  solid  organs  within  the  abdomen,  and 
thus  detecting  alterations  in  their  size,  the  surgeon  resorts  to  manipulation 
and  percussion.  In  the  same  way  the  form  of  the  organ  can  be  ascertained, 
as  in  displacement  of  the  kidney,  distension  of  the  gait  bladder  or  of  the  uri- 
nary bladder,  and  fibroma  of  the  uterus.  Accumulations  of  fluid  within 
the  abdomen,  either  cystic  or  peritoneal,  are  to  be  recognized  by  palpation,  by 
use  of  the  grooved  needle,  or  by  employment  of  the  aspirating  trocar.  The 
differentiation  of  fluids  taken  from  the  abdomen,  and  their  relation  to  special 
diseases,  will  be  materially  aided  by  observing  their  physical,  chemical,  and 
microscopical  characteristics.  The  thin  and  light  straw-colored  liquids  are 
generally  peritoneal  (ascites);  the  dark,  thick,  ropy,  and  gelatinous,  ovarian  ; 
and  the  clear,  limpid,  and  spontaneously  coagulating,  fluids  from  the  broad 
ligament.  A  characteristic  cell  is  also  said  by  l)rysdale  to  be  found  in  ovarian 
fluids. 

The  alvine  discharges  require  to  be  scrutinized.  Putty-colored  dejections 
point  to  hepatic  disorders,  and  are  often  found  associated  with  an  icteroid 
discoloration  of  the  conjunctiva  and  the  skin.  The  admixture  of  blood  with 
the  discharges  will  suggest  ocular,  instrumental,  or  digital  exploration  of  the 
anus  and  rectum;  since  blood,  and  often  mucus,  may  proceed  from  fissure, 
from  hemorrhoids,  from  stricture,  from  carcinoma,  or  from  syphilitic  disease. 
The  form  of  the  feces  may  also  reveal  the  existence  of  stricture,  being  in 
such  cases  small,  flattened,  angular,  or  round  like  pipe-stems.  The  character 
of  pain  (if  present),  and  the  period  at  which  it  is  developed,  will  also  aid  in 
forming  a  diagnosis  in  cases  of  anal  and  rectal  disease.  For  example,  there 
is  pain  in  defecation,  both  in  hemorrhoids  and  in  fissure;  but  in  the  former 
it  is  experienced  chiefly  at  the  time  of  evacuating  the  bowels,  soon  passing 
over  and  leaving  only  a  sense  of  warmth  for  some  time  after,  while  in  fissure 
the  pain  comes  on  at  variable  periods  after  defecation,  and  increases  in  se- 
ven 1y  for  several  successive  hours.  Tenesmus  is  a  common  symptom  of 
colitis,  but  may  be  equally  urgent  as  the  result  of  a  foreign  body  being  lodged 
in  the  lower  extremity  of  the  bowel.  When  tenesmus  is  accompanied  by 
frequent  and  small  watery  passages,  it  is  often  significant  of  rectal  impaction. 

<  rENiTO-URiNART  System. — The  sexual  systems  of  the  two  sexes  play  a  very 
important  part  in  the  causation  of  both  functional  and  organic  disorders  of 
the  human  body,  [mpotency,  the  loss  of  the  venereal  appetite,  and  unnatu- 
ral excitement,  in  the  male,  are  conditions  which  demand  for  their  proper 
understanding  a  critical  inquiry  into  the  state  of  the  brain  and  spinal  marrow, 
the  constitution  of  the  urine,  the  condition  of  the  organs  themselves,  and 
the  habits  of  the  patient.  The  connection  between  priapism  and  spinal  or 
cerebro-spinal  injuries;  between  spermatorrhoea  and  nervous  restlessness, 
with  palpitation,  dyspepsia,  and  loss  of  strength  and  spirits,  will  not  escape 
the  not  ire  of  the  careful  observer.     Ketraction  of  the  testicle,  and  pain  along 


INTERROGATION  OF  THE  INTERNAL  ORGANS.  355 

the  course  of  the  ureter,  in  renal  colic ;  pain  at  the  meatus  after  urination, 
and  elongation  of  the  prepuce,  in  vesical  calculus ;  phimosis  and  its  relation 
to  urinary  incontinence,  convulsions,  and  eczema  ;  a  diminished  and  twisted 
stream  of  water  in  stricture;  urethral  discharges  and  their  connection  with 
stricture;  and  frequent  micturition  as  an  indication  of  enlarged  prostate 
and  of  cystitis,  are  all  subjects  which  will  demand  investigation. 

The  influence  of  sound  kidneys  on  the  success  of  operations  is  such  that  no 
prudent  surgeon  would  willingly  undertake  an  operation  without  previous 
examination  of  the  urine,  unless  in  cases  where  operative  measures  were  un- 
avoidable. Examination  of  the  urine  should  include  an  investigation  of  its 
quantity,  specific  gravity,  color,  reaction,  and  composition  ;  while  the  means 
for  determining  these  points  are  measurement,  the  use  of  the  urinometer, 
ocular  inspection,  the  employment  of  chemical  reagents,  and  examination 
with  the  microscope.  The  principal  substances  to  be  sought  for  are  albumen, 
blood,  pus,  muco-pus,  sugar,  urates,  phosphates,  and  oxalates  ;  and  the  pres- 
ence or  absence  of  each  of  these  has  an  important  bearing  on  both  diagnosis 
and  prognosis. 


SHOCK. 


BY 

C.  W.  MANSELL-MOULLIN,  M.  A.,  M.D.  Oxon.,  F.R.C.S., 

FELLOW  OF  PEMBROKE  COLLEGE,   OXFORD  ;    LATE  RADCLIFFE'S  TRAVELLING  FELLOW, 
PNIV.  OXON.J    SURGICAL  REGISTRAR  TO  THE  LONDON  HOSPITAL.  LONDON. 


Originally  employed  in  any  case  of  sudden  death  or  collapse  following 
injury  or  mental  emotion  without  discoverable  lesion,  the  term  Shock  has, 
step  by  step  with  the  increase  in  knowledge  of  physiology  and  the  extension 
of  experimental  inquiry,  become  more  and  more  definitely  associated  with 
the  conception  of  a  sudden  check  to  the  circulation  brought  about  throuo-h 
the  agency  of  the  nervous  system,  and  resulting  either  in  a  death  so  immedi- 
ate as  scarcely  to  have  a  parallel,  or  in  a  condition  of  prolonged  prostrat  ion 
with  or  without  a  more  or  less  successful  reaction.  Such  a  result  can  only 
take  place  through  the  direct  influence  of  the  nervous  system.  Long  ago, 
Travers1  pointed  out  that  frequent  instances  of  sudden  death,  consequent  upon 
injuries  which  left  no  trace  of  their  destructive  operation  upon  the  texture 
of  the  vital  organs,  and  that  other  instances  of  death  after  the  lapse  of  a  few 
hours  or  days,  and  some  even  of  weeks,  from  the  injury,  admitted  of  no  other 
explanation  according  in  any  degree  with  the  history  and  symptoms  of  the 
malady,  than  a  suspension  or  failure  of  the  nervous  power.  Isor  is  it  less 
clearly  proved  by  the  spontaneous  disappearance  of  all  symptoms  in  cases  of 
recovery,  sometimes  almost  as  rapid  as  their  onset  (for  patients  left  pulseless 
and  apparently  moribund,  without  external  injury,  may  be  found  on  the 
succeeding  day  restored  to  the  tone  and  tranquillity,  comparatively  speaking, 
of  health),  that  there  can  be  associated  with  it  no  serious  structural  lesion. 
Of  course  it  must  not  be  inferred  that  no  change  at  all  has  taken  place,  but 
simply  that  it  is  not  within  range  of  perception  by  means  of  our  present 
niethods  of  investigation  ;  and,  indeed,  it  is  to  be  expected  that,  with  increas- 
ing knoweledge  of  the  conditions  under  which  the  manifestation  of  that  form 
of  molecular  motion  known  as  nerve-force  is  possible,  we  shall  some  day  be 
able  to  form  an  idea  of  the  way  in  which  its  action  may  be  modified  or  sus- 
pended, without  the  production  of  any  visible  alteration  of  structure. 


Causes  of  Shock. 

"Whatever  may  be  the  immediate  cause  of  shock,  whether  it  result  from  a 
purely  mental  source  or  from  a  serious  bodily  hurt  (for  probably  either  alone 
is  sufficient,  although  in  general  each  bears  a  share),  everything  denotes  dimin- 
ished energy  of  circulation :  the  pallor  and  coldness  of  the  skin,  the  weak- 
ness and  small  volume  of  the  pulse,  the  difficulty  of  respiration,  the  languor 


Treatise  on  Constitutional  Irritation,  p.  431. 

(357) 


358  shock. 

and  general  depression,  all  point  to  some  failure  among  those  forces  that  main- 
tain the  circulating  fluid  at  the  necessary  tension  ;  to  some  difficulty  affecting 
the  motive  impulse  of  the  heart,  or  the  peripheral  resistance  of  the  capillaries, 
or  the  state  of  tone  of  the  smaller  vessels,  arteries  as  well  as  veins;  for  these 
are  the  forces  mainly  concerned  in  keeping  up  the  arterial  pressure  on  which 
the  circulation  depends.  That  the  first  of  these  three,  the  heart,  is  affected, 
can  have  escaped  the  notice  of  none  who  have  ever  experienced  emotion  of 
any  kind ;  with  regard  to  the  others,  there  would  be  greater  doubt  if  it  had 
not  been  proved  by  experimental  demonstration  ;  though  it  might  reasonably 
have  been  surmised  from  the  well-known  occurrence  of  syncope,  in  failure  of 
the  heart's  power  from  organic  disease  or  other  causes,  that  for  the  production 
of  shock,  unattended  by  loss  of  consciousness,  some  additional  element  must 
be  present.  With  regard  to  the  causes  of  shock,  there  can  be  no  doubt  that 
mental  emotion,  especially  joy  or  fear,  of  itself,  without  bodily  hurt  of  any 
kind,  may  be  followed  by  the  gravest  form  of  shock,  resulting  in  immediate 
death  even  where  there  is  no  probability  of  organic  disease  of  the  heart. 

Many  years  ago,  the  janitor  of  a  college  had  rendered  himself  in  some  way  obnox- 
ious to  the  students,  and  they  determined  to  punish  him.  They  accordingly  prepared 
a  block  and  axe,  which  they  conveyed  to  a  lonely  place,  and,  having  dressed  themselves 
in  black,  some  of  them  prepared  to  act  as  judges,  and  sent  others  of  their  company  to 
bring  him  before  them.  When  he  saw  the  preparations  that  had  been  made,  he  at  first 
affected  to  treat  the  whole  thing  as  a  joke,  but  was  solemnly  assured  by  the  students 
that  they  meant  it  in  real  earnest.  He  was  told  to  prepare  for  immediate  death,  for 
they  were  going  to  behead  him  then  and  there.  The  trembling  janitor  looked  all  around 
in  the  vain  hope  of  seeing  some  indication  that  nothing  was  really  meant,  but  stern 
looks  everywhere  met  him,  and  one  of  the  students  proceeded  to  blindfold  him.  The 
poor  man  was  made  to  kneel  before  the  block,  the  executioner's  axe  was  raised,  but, 
instead  of  the  sharp  edge,  a  wet  towel  was  brought  smartly  down  on  the  back  of  the 
culprit's  neck.  This  was  all  that  the  students  meant  to  do,  and,  thinking  that  they  had 
frightened  the  janitor  sufficiently,  they  undid  the  bandage  which  covered  his  eyes.  To 
their  astonishment  and  horror,  they  found  that  he  was  dead.1 

And  although  this  extreme  effect  may  not  be  common,  instances  of  cata- 
lepsy, hysteria,  idiocy,  and  other  morbid  mental  conditions  are  in  plenty  :  nor 
can  this  be  in  any  way  a  matter  for  astonishment,  when  the  effects  of  mental 
impressions  on  the  functions  of  the  body  are  taken  into  consideration.  A 
familiar  instance  of  their  influence  is  seen  in  women  during  lactation:  the 
qualities  of  the  milk  are  from  this  cause  often  suddenly  changed  so  as  to  pro- 
duce very  serious  effects  upon  the  infant :  in  some  recorded  cases  the  result 
has  proved  fatal.  It  is  remarkable  and  characteristic  that  severe  shocks  to 
the  system  from  mental  emotion,  after  the  more  immediate  effects  have  passed 
away,  often  leave  some  organ  permanently  impaired  in  its  function.  Sudden 
fright,  for  instance,  has  produced  deafness.2 

There  is,  however,  in  individuals  the  greatest  possible  difference  in  this 
respect.  No  two  persons  are  ever  affected  in  the  same  way  by  mental  emo- 
tion, or  to  the  same  degree:  some  are  but  slightly  moved  by  that  which 
influences  others  in  a  most  serious  manner;  others  again  are  greatly  disturbed 
by  slight  accidents  of  some  special  kind,  while  they  are  altogether  heedless 
altout  troubles  much  more  grave;  and  under  different  circumstances,  at  dif- 
fered times  of  life — nay,  even  at  different  times  of  the  day — the  same  people 
may  remain  apparently  unconcerned, or  be  quite  overcome.  Yet  sometimes, 
when  the  temperament  and  nervous  susceptibility  of  a  patient  are  well  known, 
a  prediction  may  he  hazarded  as  to  the  probable  effect  of  an  injury  or  opera- 

1  Lauder  Brunton,  Shook  and  Syncope. 

2  Savory,  Collapse  ;   Holmes's  System  of  Surgery. 


CASES  ATTENDED  BY  SHOCK.  359 

tion,  and  timely  help  be  thus  gained  in  the  question  of  prognosis.  Sex  is  not 
without  its  influence,  though  it  is  scarcely  possible  to  estimate  how  far  sus- 
ceptibility to  shock  is  due  to  difference  inhabits  of  life  ami  physical  develop- 
ment, and  how  far  to  a  quicker  sympathy  and  more  ready  emotion.  The 
effects  of  age  on  the  production  and  course  of  shock  are  more  certain,  espe- 
cially if  account  be  taken  of  the  complete  absence  of  anxiety  in  the  young, 
and  of  the  apathy  so  common  in  the  old.  It  is  generally  said  that  the  imme- 
diate results  of  an  injury  are  worse  at  these  two  periods  of  life  than  at  any 
other;  but,  in  the  case  of  the  young,  much  allowance  must  be  made  for  the 
relative  amount  of  damage  sustained,  for  the  very  serious  effect  of  even,  com- 
paratively speaking,  a  slight  loss  of  blood,  and  for  the  great  susceptibility  to 
eold.  In  the  aged,  shock  is  more  particularly  characterized  by  uncertainty, 
both  as  to  its  course  and  persistence ;  not  unfrequently  its  intensity  is  dimin- 
ished and  its  duration  prolonged ;  and  often,  when  all  seems  going  on  well, 
the  heart's  strength  fails  suddenly,  and  the  patient  dies  when  least  expected. 
It  must  be  mentioned,  however,  that  Xussbaum  and  others  will  not  admit 
cases  of  this  kind  as  examples  of  death  from  shock,  believing  that  hemor- 
rhage, by  means  of  the  effects  that  may  follow  it  even  after  some  time  has 
elapsed,  is  much  more  likely  to  have  been  the  cause  of  the  fatal  issue. 

Pain,  when  intense  and  unintermitting,  has  been  known  to  prove  fatal,  but 
probably  in  the  majority  of  cases  by  inducing  syncope,  though  it  has  a  dis- 
tinct effect  upon  the  heart's  action ;  patients,  while  in  a  state  of  shock, 
whether  arising  from  bodily  or  mental  origin,  seldom  feel  any  but  the  most 
acute  agony;  and  in  many  of  the  examples  brought  forward,  protracted 
labors  for  instance,  extreme  muscular  exhaustion  has  been  of  material  help 
in  causing  death.  It  is  more  singular  that,  as  Astlcy  Cooper  pointed  out,  the 
moment  of  transition  from  intense  agony  to  perfect  ease  has  been  known  to 
prove  fatal. 

Deep  mental  ^re-occupation ,  generally  met  with  under  the  form  of  extreme 
excitement,  undoubtedly  possesses  the  peculiar  poAver  of  postponing  the  occur- 
rence of  shock,  perhaps  in  the  same  way  that  the  will,  or  the  violent  irrita- 
tion of  a  sensory  nerve,  can  for  a  time  suspend  perception.  It  is  especially  in 
military  surgery  that  cases  of  this  kind  are  recorded — where  serious  and 
painful  wounds  are  not  oven  known  of,  till  long  after  their  infliction.  It  is 
only  the  onset  of  the  shock,  however,  that  is  delayed:  its  intensity  loses 
nothing  from  the  combined  effect  of  the  injury,  pain,  commencing  fever, 
exhaustion,  fear,  and  perhaps  even  despair.  Another  mental  condition  that 
may  lie  mentioned  as  having  a  peculiar  influence  is  that  of  intense  and  per- 
haps delayed  expectation  ;  at  least  it  would  seem  that  this  might  assist  in  the 
explanation  of  those  deaths,  the  most  mysterious  of  all,  which  follow  imme- 
diately on  some  trivial  operation,  while  accidents  seem  to  be  without  effect ; 
perhaps  there  may  be  a  comparison  between  these  cases  and  those  already 
mentioned  of  sudden  death  on  the  cessation  of  pain;  in  each  it  seems  to 
follow  the  breaking  off  of  a  condition  of  extreme  mental  tension. 


Cases  attended  by  Shock. 

The  majority  of  the  cases  of  shock  met  with  in  surgical  practice,  follow 
accidents  or  operations,  serious  either  from  the  actual  extent  of  the  injury 
inflicted,  or  from  the  fact  that  special  organs  or  textures  have  been  involved. 
Hums  and  scalds,  especially  when  the  area  involved  is  extensive,  even  if  the 
depth  is  insignificant,  are  among  the  most  common  causes  of  shock  ;  then  come 
contused  and  lacerated  wounds,  such  as  are  produced  by  the  violent  crushing 
ot  a  limb,  and  capital  operations,  though  by  care  and  attention  in  the  case  of 


360  SHOCK. 

these,  the  severity  of  the  resulting  shock  may  be  much  reduced.  In  all,  the 
danger  is  great  in  proportion  to  the  proximity  of  the  injury  to  the  trunk,  a 
fact  that  is  conclusively  shown  by  the  results  of  amputations  on  the  lower 
limbs;  and  it  would  seem  as  if  the  injury  to  the  bone  itself  had  some  special 
influence,  for  Pirogoff1  saw  two  men  die  on  the  table  during  amputation 
through  the  thigh  (one  for  injury,  the  other  for  chronic  disease  of  the  knee- 
joint),  at  the  instant  that  the  bone  was  being  sawn  through  ;  a  spasmodic 
contraction  passed  over  the  muscles  of  the  body,  the  face  became  pale,  the 
eyes  lost  their  lustre,  the  pupils  dilated,  and  death  followed  at  once — in 
neither  case  was  an  anaesthetic  administered.  Furneaux  Jordan2  too,  watch- 
ing a  thermometer  placed  in  the  axilla,  while  an  amputation  was  being  per- 
formed, observed  on  several  occasions  a  drop  of  as  much  as  one-fifth  of  a 
degree  during  the  application  of  the  saw.  There  is  a  special  gravity  attached 
to  those  cases  of  shock  which  result  from  railway  accidents,  probably  in  no 
small  measure  owing  to  the  part  taken  in  their  production  by  mental  causes, 
and  to  the  general  concussion  sustained  by  the  body  in  its  suddenly  suspended 
motion ;  for  instances  of  severe  and  lasting  shock,  often  assuming  most 
insidious  forms,  are  met  with  from  time  to  time  in  occurrences  of  this  kind, 
without  there  being  any  definite  or  marked  bodily  lesion,  and,  indeed,  are 
often  the  more  severe  when  this  is  quite  absent,  and  there  is  no  other  expla- 
nation than  a  general  or  mental  cause. 

Simple  concussion  of  the  brain  would  present  a  frequent  and  good  example 
of  shock,  if  it  were  possible  to  eliminate  and  set  aside  the  symptoms  that 
depend  upon  the  injury  inflicted  on  the  brain-substance  itself,  probably  presei it 
in  all,  even  the  slightest  cases,  and  productive  of  indirect  as  well  as  of  direct 
results,  if  any  reliance  is  to  be  placed  on  experimentation.3 

As  accidents  involving  the  extremities  are  followed  by  shock,  other  things 
being  equal,  in  proportion  to  their  proximity  to  the  trunk,  so  it  might  rea- 
sonably be  supposed  that  injuries  inflicted  on  the  trunk  itself  would  present 
cases  of  the  greatest  severity ;  and  this  is  true  not  only  of  accidents  that 
involve  considerable  damage  to  organs  or  textures — damage  that  might  of 
itself  render  difficult  the  continuance  of  functions  necessary  to  the  mainten- 
ance of  life, — but  also  of  slighter  injuries,  blows  or  contusions,  that  in  other 
parts  of  the  body  would  scarcely  be  noticed,  but  which  here  are  often,  and 
sometimes  unexpectedly,  followed  by  results  of  the  gravest  character.  Few 
can  have  passed  through  school-life  without  having  experienced  the  effect  of 
a  blow  on  the  scrotum,  or  on  the  pit  of  the  stomach :  the  intense  collapse  and 
complete  prostration  that  supervene  at  once,  and  may  even  terminate  fatally, 
as  cricketing  annals  unhappily  show.  Fischer4  relates  a  case  of  death  with 
all  the  symptoms  of  the  deepest  shock,  following  a  few  hours  after  a  testicle 
hud  been  crushed  ;  and  Erichsen  mentions  as  a  frequent  occurrence  in  castra- 
tion, the  sinking  of  the  pulse  at  the  moment  of  division  of  the  spermatic 
cord,  even  when  the  patient  is  fully  under  the  influence  of  an  anaesthetic. 
But  it  is  not  a  little  singular  that,  in  spite  of  the  generally  received  tradition 
on  such  matters,  and  of  the  undeniably  grave  symptoms  which  are  so  notori- 
ously produced,  there  should  not  be  recorded  one  single  case  in  which  death 
has  followed  in  a  healthy  man  immediately  upon  a  blow  on  the  abdomen, 
without  injury  to  any  of  the  subjacent  viscera.  Even  the  classical  instance 
given  by  Sir  Astley  Cooper,  and  always  quoted  as  an  example,  of  the  laborer 
who  while  wheeling  a  harrow,  received  a.  slight  blow  in  the  epigastrium  and 
tell  down  (lead,  eai 1 1 lot  he  admitted,5  though  it  is  siq (ported  by  such  authority; 
lor  it   did   not  occur  within  his  own  practice,  and  in  the  account  left  of  it 

1  Kri<vKsoliimrgie,  S.  89.  2  Hastings  Essay  on  Shock. 

3  Goltz,  Pfltiger's  Archiv,  187fi.  *  Volkmanu's  Saramlung  klinischer  Vortriige,  No.  10. 

6  Pollock,  Holmes's  System  of  Surgery. 


CASES  ATTENDED  BY  SHOCK.  361 

there  is  nothing  that  is  inconsistent  with  the  idea  of  sudden  failure  of  the 
heart's  action,  from  the  combined  effects  of  degenerated  structure  and  over- 
exertion. Death  may,  however,  occur  at  a  later  period;  a  boy  after  being 
crushed  by  the  end  of  a  costermonger's  barrow  against  a  wall,  was  admitted 
to  hospital  in  a  state  of  collapse,  from  which  he  partially  rallied  towards 
evening,  only  to  sink  again  gradually  before  twenty-four  hours  had  elapsed  ; 
nor  was  there  anything" found  after  death  that  could  account  for  this;  only  a 
little  redness  and  stickiness  of  the  peritoneum  in  one  small  spot  behind, 
'against  the  vertebra?,  as  of  commencing  peritonitis, 
"it  often  happens  that  'penetrating  wounds  of  the  abdomen,  and  still  more 
frequently  that  injuries  or  operations  involving  the  handling  of  the  viscera, 
such  as  ovariotomy,  are  followed  by  results  of  this  nature,  though  exceptions 
are  more  frequently  met  with  in  this  class  of  injuries  perhaps  than  elsewhere. 
Death  within  five  minutes  has  occurred  after  such  a  simple  operation  as  tap- 
ping the  liver  for  hydatid  disease. 

The  patient,  a,  man  id  years  of  age,  to  all  appearance  perfectly  healthy,  and  temper- 
ate, presented  himself  on  account  of  an  enlargement  of  the  abdomen  which  had  been 
noticed  some  ten  months.  It  was  plainly  a  case  of  hydatid  disease  of  the  liver  ;  and 
was  of  such  inconvenience  that  the  man  wished  something  to  be  done.  After  some  days 
in  the  ward,  a  fine  aspirating  trocar  and  canula  were  introduced  without  any  anaesthetic, 
and  a  few  drops  of  clear  fluid  evacuated  ;  as  no  more  followed,  a  canula  somewhat  larger, 
about  the  size  of  a  small  goose-quill,  was  inserted  through  the  same  opening  immedi- 
ately on  withdrawal  of  the  smaller  one.  A  few  drachms  of  blood-stained  fluid  came, 
and  then  all  of  a  sudden  the  patient's  face  became  pale  and  livid,  his  arms  sank  down 
by  his  side,  and,  with  the  exception  of  a  few  faint  irregular  beats,  the  pulse  ceased. 
At  the  post-mortem  examination,  on  the  following  day,  the  puncture  was  found  on  the 
convexity  of  the  liver,  and  a  probe  was  passed  through  it  into  a  small  cyst  lying  by  the 
side  of  a  much  larger  one  ;  there  was  no  great  distension  of  the  abdominal  veins,  and 
the  only  sign  of  visceral  degeneration  was  a  slightly  granular  condition  of  the  kidneys. 

Bryant1  relates  a  very  similar  case,  except  that  the  amount  of  fluid  removed 
was  considerably  greater,  about  nine  ounces  (though  much  more  than  this  has 
frequently  been  withdrawn  without  damage),  and  that,  while  the  inferior  vena 
cava  was  considerably  obstructed  by  the  pressure  of  the  tumor,  a  large  branch 
of  the  portal  vein  had  been  perforated  by  the  trocar. 

Injuries  to  other  abdominal  viscera  offer  examples  no  less  frequent  and  quite 
as  characteristic.  The  strangulation  of  a  portion  of  small  intestine,  whether 
in  a  hernial  sac  or  by  some  band  within  the  abdominal  cavity,  is  attended  at 
once  by  symptoms  of  the  most  complete  prostration,  and  may  of  itself,  if  left 
unreduced,  be  sufficient  to  occasion  death,  without  the  production  of  perito- 
nitis. Many  more  instances  are  on  record  of  this  result  having  followed  the 
application  of  taxis,  with  or  without  the  administration  of  chloroform,  espe- 
cially in  the  case  of  umbilical  or  ventral  hernia?  in  corpulent  subjects  reduced 
by  long-continued  vomiting. 

The  same  effects  are  produced  by  large  doses  of  corrosive  poisons,  such  as 
sulphuric  and  other  mineral  acids,  or  arsenic,  the  immediate  effects  of  which 
are  intense  local  pain,  coldness  and  pallor  of  the  surface,  sighing  respiration, 
and  a  weak,  perhaps  imperceptible  pulse.  Similar  results  follow  when  per- 
foration takes  place  in  the  stomach  or  intestines,  and  their  contents  escape 
into  the  peritoneal  cavity.  The  occurrence  of  shock  after  parturition,  espe- 
ciallyin  the  case  of  bearing  twins,  is  probably  partly  due  to  nervous  influence, 
and  partly  to  the  removal  of  pressure  from  the  abdominal  vessels  by  the  loss 
of  such  a  large  portion  of  the  abdominal  contents,  which  must  almost  un- 
avoidably occasion  more  or  less  relaxation  of  the  vessels.2 

1  Lancet,  June  8,  1878.  8  Lauder  Brunton,  Shock  and  Syncope. 


362  shock. 

Great  loss  of  blood,  especially  if  it  has  taken  place  suddenly,  brings  on  all 
the  symptoms  of  collapse,  but  usually  accompanied  by  syncope  ;  and  certain 
poisons  (as  nicotin  and  muscarin)  which  act  directly  on  that  part  of  the  nervous 
system  that  is  in  immediate  relation  with  the  heart  and  vessels,  produce  the 
most  intense  prostration  of  mental  and  bodily  vigor  through  the  diminution 
of  vascular  tension,  and  these  cases  are  of  more  than  ordinary  interest,  for  in 
this  way  the  practical  physiologist  is  able  at  will,  by  methods  the  working  of 
which  is  fairly  well  understood,  to  produce  a  condition  not  to  be  distinguished 
by  any  of  its  symptoms  from  that  consequence  of  injury  or  mental  emotion 
which  has  been  so  long  unintelligible.  Indeed,  so  close  is  the  resemblance 
presented  by  cases  of  this  kind  to  the  collapse  caused  by  abdominal  injury, 
for  example,  that  Furneaux  Jordan  and  others  have  included  hemorrhage  and 
this  class  of  poisons  among  the  causes  of  shock.  But  it  would  seem  alto- 
gether more  reasonable  to  restrict  the  definition,  by  retaining  the  idea  of  in- 
direct, perhaps  reflex  (whether  traumatic  or  mental)  origin,  and  to  regard 
these  cases  in  which  the  result  is  produced  by  some  influence  acting  directly 
on  the  vascular  tension,  as  a  means  of  explaining  those  in  which  the  same  is 
brought  about  indirectly  and  refiexly  as  the  consequence  of  some  perhaps 
distant  injury. 

Symptoms  of  Shock. 

Few  conditions  are  more  characteristic  than  that  of  a  patient  suffering  from 
the  graver  effects  of  shock  ;  none  resemble  death  itself  more  closely.  lie  lies 
perfectly  quiet,  giving  no  heed  to  anything  that  goes  on  around  ;  with  limbs 
helpless  and  prostrate,  as  they  may  be  placed,  or  as  the  chance  of  the  moment 
may  dictate ;  conscious,  yet  seeing  only  in  a  mist,  and  hearing  none  but  loud 
and  repeated  questions  (though  rare  instances  are  met  with  in  which  the  senses, 
especially  the  hearing,  are  acute  beyond  all  measure);  with  no  paralysis,  yet 
replying  with  difficulty,  in  a  syllabic,  scarcely  audible  voice,  and  only  executing 
with  painful  slowness  some  simple  movements  often  left  half  finished.  The 
expression  of  the  face  is  quite  changed  ;  all  the  features,  especially  the  nose, 
are  smaller  and  shrivelled ;  the  weary  eyes  have  lost  their  lustre,  and  lie 
rolled  upwards  in  deeply  sunken  sockets,  surrounded  by  a  dusky  ring ;  the 
pupils  in  general  are  dilated,  and  react  very  slowly  to  the  stimulus  of  light. 
The  skin,  and  such  parts  of  the  mucous  membrane  as  are  visible,  are  pale, 
but  livid  too;  the  fingers  and  nails  blue,  and  the  skin  on  the  palmar  aspect 
hanging  in  loose  folds.  Large  drops  of  sweat  hang  on  the  forehead  and  eye- 
brows;  the  whole  body  is  cold;  at  times  a  shiver  passes  through  all  the 
limbs ;  and  the  loss  of  temperature  is  often  so  great  as  to  make  the  ther- 
mometer fall  two  or  more  degrees.  Common  sensibility  and  the  sense  of  pain 
arc  much  blunted  over  the  whole  body  ;  only  some  paroxysm  more  sharp  than 
ordinary  can  rouse  to  any  movement,  while  the  worst  of  news  is  heard  with- 
out emotion,  so  great,  is  the  already  existing  depression.  The  pulse  is  almost 
imperceptible,  irregular,  unequal,  and  very  rapid;  the  arteries  are  small  and 
the  tension  low;  the  ascent  in  a  sphygmographie  tracing  is  very  short  and 
sloping,  but  the  apex  fairly  well  marked  ;  the  presence  of  dicrotism  in  these 
cuses  probably  depends  upon  the  amount  of  hemorrhage.  The  respiratory 
movements  are  very  irregular— abnormally  deep,  sighing  inspirations  break- 
ing suddenly  into  :i  series  of  very  superficial  ones  which  are  scarcely  audible; 
sometimes,  especially  as  the  graver  symptoms  are  passing  oil'  and  reaction  is 
beginning  to  se1  in,  there  is  vomiting;  the  sphincters  generally  remain  closed, 
but  no  rule  can  be  laid  down  upon  this  point;  retention  of  urine  occurs  per- 
haps more  frequently  than  not,  and  sometimes,  with  this,  there  is  partial  sup- 
pression. 


SYMPTOMS   OF   SHOCK.  363 

This  death-like  calm  is,  however,  by  no  means  invariable  in  cases  of  shock; 
indeed,  in  this  respect  they  may  present  the  greatest  possible  variety.  There 
may  be  from  the  first  a  condition  of  the  most  extreme  restlessness  and  excita- 
bility, that  erethistic  form  which  Travers  has  termed  "prostration  with  ex- 
citement;" or  this  may  follow  on  the  former  type  as  a  kind  of  reaction. 

The  patient  then  tosses  wildly  and  vaguely  from  side  to  side,  as  if  frantic, 
complaining  of  a  fearful  oppression  and  want  of  breath;  with  presentiments 
of  death,  and  a  feeling  of  total  annihilation;  often  shouting  again  and  again 
The  same  thing,  perhaps  utterly  meaningless;  with  a  countenance  expressive 
of  nothing  but  a  nameless  anxiety  and  excruciating  agony.  No  encourage- 
ment is  of  any  use;  the  consciousness  is  unclouded,  but  seems  altogether  pre- 
occupied by  the  frightful  anguish ;  no  question  is  answered ;  there  is  only 
the  same  constant  moaning  exclamation;  no  attention  is  paid  to  anything 
going  on  around;  there  is  but  one  feeling,  that  of  closely  impending  dissolu- 
tion. The  respiration  and  pulse  present  the  same  general  character  as  in 
the  torpid  form  of  shock,  but  it  is  seldom  that  the  pallor  and  coldness  are  so 
great;  sometimes  even  the  face  is  flushed, and  burning  thirst  is  nearly  always 
felt;  fluids  are  swallowed  with  the  greatest  eagerness,  and  vomited  as  soon. 
Often  the  limbs  or  the  whole  body  are  convulsed  by  a  sudden  rigor.  Sleep  is 
unknown,  or  there  is  at  best  a  fitful  slumber  which  gives  no  relief;  more 
often,  as  night  approaches,  the  incoherence  becomes  wild  delirium.  Ex- 
haustion rapidly  supervenes;  a  profuse  and  clammy  sweat  appears  on  the 
face,  and  spreads  over  the  whole  body;  the  pulse  becomes  fainter  and  feebler, 
and  with  a  sudden  cessation  of  all  movement,  often  preceded  by  a  slight  con- 
vulsion, the  expression  alters,  and  the  patient  is  dead. 

In  spite  of  the  very  great  difference  in  the  external  manifestations  of  these 
two  forms  of  shock,  it  is  by  no  means  improbable,  just  as  under  other  circum- 
stances coma  and  convulsions  may  occur  together,  and  be  due  to  the  same 
cause,  that  the  same  pathological  condition  underlies  them  both — of  course  in 
somewhat  different  measure ;  at  least,  the  distinction  is  so  slight  that  either 
may  succeed  the  other,  and  no  prediction  as  yet  is  possible  either  from  the 
constitution  of  the  patient  or  the  nature  of  the  lesion,  as  to  which  may  be  the 
form  which  will  supervene. 

But  even  these  are  not  the  only,  though  they  are  perhaps  the  most  striking, 
forms  in  which  the  intense  depression  of  vital  power  that  follows  serious 
injury  may  manifest  itself.  Sometimes,  and  it  is  more  particularly  after  rail- 
way injuries,  as  a  result,  perhaps,  of  the  fright — perhaps  of  the  violent  concus- 
sion sustained  by  the  whole  body  as  it  is  violently  projected  into  space,  or 
jerked  backwards  and  forwards  with  all  the  muscles  unprepared — there  is 
seen  a  form  so  insidious  as  to  falsify  the  most  guarded  prognosis.  After  the 
accident,  the  patient,  who  has  sustained  no  apparent  bodily  hurt  (and  this 
seems  to  be  essential),  appears  perfectly  calm  and  unaffected — often  unnatu- 
rally so — congratulating  himself  on  his  escape;  his  color  is  good  ;  pulse  quiet; 
respiration  tranquil ;  there  seems  nothing  wrong.  But  at  night  there  comes  an 
inability  to  sleep,  and  a  tendency  to  become  feverish ;  the  pulse  becomes  quicker 
and  softer;  the  eye  bright  and  restless;  the  extremities  cool;  and,  even  within 
the  space  of  three  or  four  days,  persistent  vomiting  and  exhaustion,  running 
on  to  prostration  and  coma,  may  supervene.  More  frequently  the  time  occu- 
pied is  much  longer,  and  there  follows  a  condition  which  has  been  variously 
called,  for  want  of  a  better  name,  hysteria,  or  hypochondriasis.  It  is  true 
that  much  doubt  has  been  justly  thrown  on  a  great  number  of  these  cases;  in 
many,  the  symptoms  have  been  simulated  completely ;  in  others,  and  proba- 
bly the  greater  number,  the  real  cause  has  been  a  slowly  progressing,  chronic 
cerebrospinal  meningitis;  but  there  still  remain  a  few  (presenting  no  objec- 
tive signs)  to  which  this  explanation  will  not  apply;  a  few  in  which,  as  the 


364  shock. 

result  of  an  accident,  and  coming  on  too  soon  afterwards  for  inflammation  to 
be  the  cause,  there  has  followed  either  some  defect  or  perversion  of  nutrition, 
or  more  or  less  complete  loss  of  that  which  may  be  most  aptly  compared  with 
what  is  known  in  physiology  as  inhibition — moral  control.  It  has  been  said 
that  this  condition  is  really  due  to  anaemia  of  the  spinal  cord ;'  it  may  be  so, 
and  this  state  presents  a  certain,  but  by  no  means  close,  analogy  to  a  somewhat 
similar  condition  of  the  brain;  but  while  it  is  exceedingly  hard  to  understand 
how  such  a  condition  could  have  arisen  primarily,  it  is  still  more  difficult  to 
imagine  how  it  could  persist;  and  it  must  always  be  recollected  that  it  is  a 
doctrine  resting  on  clinical  evidence  only,  there  being  no  pathological  fact 
that  can  be  urged  in  its  support. 

It  must,  however,  always  be  remembered  that  it  is  essential  to  the  concep- 
tion of  shock,  that  the  symptoms,  or  some  of  them  in  their  lighter  form, 
should  make  their  appearance  immediately  after  the  accident,  It  cannot  -be 
doubted  that  many  of  the  cases  of  sudden  death  which  have  hitherto  been 
placed  in  the  category  of  shock — cases  in  which  an  interval  of  some  hours,  or 
even  days,  have  elapsed  after  the  receipt  of  an  injury  or  the  performance  of 
an  operation  without  the  appearance  of  any  untoward  complication— have  not 
been  due  at  all  to  shock  in  the  strict  sense  of  the  term,  regarding  it  as  ex- 
treme vital  depression  caused  by  reflex  nerve-influence.  The  greater  number 
may  probably  be  accounted  for  by  hemorrhage,  especially  those  later  effects  of 
it  to  which  Nussbaum2  attributes  the  strange  results  of  accidents  in  advanced 
life ;  or  by  septic  collapse,  from  the  sudden  absorption  of  poisonous  matters  by 
a  large  serous  surface,  such  as  the  peritoneum ;  or  by  fatty  embolism,  which 
has  been  shown  of  late  by  "Wagner  and  others  to  be  strangely  frequent  after 
injuries,  especially  when  involving  bones. 

The  symptoms  of  shock  do  not  by  any  means  always  present  the  gravity  of 
the  cases  described  above;  there  may  be  merely  a  temporary  impairment  of 
mental  vigor,  with  a  transient  diminution  of  muscular  energy,  and  a  slight 
irregularity  in  the  heart's  action ;  signs  which  it  is  very  hard  to  distinguish 
from  those  of  syncope,  if  indeed  it  is  possible.  Travers3  has  said  that  a  fit  of 
syncope  and  the  recovery  from  it  present  an  epitome  of  the  phenomena  of 
shock. 

There  is,  however,  in  syncope  one  characteristic  feature — so  characteristic  as 
to  have  given  it  its  name — which  is  very  rarely  met  with  in  shock,  perhaps 
never  but  in  those  cases  which  have  a  rapidly  fatal  termination;  and  this  is 
the  sudden  and  complete  loss  of  consciousness  always  present,  and  due  to  the 
suspension  of  the  function  of  those  parts  of  the  brain  which  have' to  do  more 
especially  with  the  intelligence.  It  is  scarcely  necessary  to  bring  forward 
evidence  at  any  length  to  prove  that  deficiency  in  the  supply  of  blood  to  the 
brain  is  the  pathological  condition  underlying  the  symptoms  of  syncope;  the 
striking  pallor  of  (he.  face,  coming  so  suddenly,  would  alone  be  almost  suffi- 
cient;  or  any  of  those  cases  in  which  the  heart  being  enfeebled,  the  sudden 
assumption  of  the  erect  posture  is  at  once  followed  by  loss  of  consciousness — 
even  if  Sir  Astlev  (doper,  by  ligaturing  the  carotids,  and  Flemming,  by  com- 
pressing them,  had  not  shown  beyond  all  question  that  it  is  the  local  change 
thai  is  the  cause.  Nor  is  there  any  anatomical  difficulty  in  the  supposition 
of  a  sudden  diminution  in  the  quantity  of  blood  entering  the  cranial  cavity, 
for  this  is  no  longer  regarded  as  closed,  but  as  having  sufficiently  free  com- 
munication  between  the  ventricles  and  the  subarachnoid  spaces  to  enable  the 
alteration  in  pressure  to  receive  immediate  compensation.  In  shock,  on  the 
other  hand,  it  is  rare  lor  the  loss  of  consciousness  to  be  complete:  the  brain 

1  Eriehsen,  Railway  Injuries.  2  Arztlichea  Intolligenz-Blatt,  Marz  13,  1877. 

*  Op.  oit.,  \>.  467. 


PATHOLOGY   OF   SHOCK.  365 

is  still  active,  though  quite  unequal  to  the  higher  efforts  of  intelligence ;  its 
power  is  impaired,  not  abolished  ;  and,  as  in  syncope  it  appears  to  be  the  only 
part  of  the  nervous  system  (as  far  as  it  is  admissible  to  use  the  expression) 
atfected,  so  in  shock  it  sutlers  equally  with  all  the  rest;  for  in  the  one,  the 
simplest  cause  that  is  efficient,  is  a  diminution  of  the  blood  pressure  within 
the  cranial  cavity  ;  in  the  other,  the  only  one  that  can  oiler  any  explanation 
of  the  symptoms,  is  a  fall  in  the  vascular  tension,  which  is  general,  extending 
throughout  the  whole  body.  Even  when  there  has  been  no  loss  of  blood,  the 
lividity  and  pallor  of  the  skin  ;  the  diminution  in  sensibility ;  the  sluggish- 
ness of  the  cerebral  functions;  the  lessened  vigor  of  contraction  and  readiness 
to  respond  to  stimulus,  shown  by  the  muscles;  the  rapidity,  smallness  of 
volume,  and  compressibility  of  the  pulse  ;  the  partial  suppression  of  the  secre- 
tions ;  and  especially  the  long  continuance  of  the  symptoms,  which  are  not 
capable  of  passing  off  within  a  few  minutes,  as  in  syncope — all  point  to  some 
general  check  to  the  capillary  circulation,  and  through  this  to  an  equally 
general  failure  in  the  arterial  tension. 


Pathology  of  Shock. 

It  is  to  experimental  physiology  alone  that  must  be  given  the  credit  of  not 
merely  a  plausible,  but  almost  certainly  the  true  explanation  of  the  manner 
in  which  these  changes  can  take  place.  It  has  shown  that,  while,  on  the  one 
hand,  the  heart  is  so  independent  of  other  innervation  than  that  contained 
within  its  own  walls,  for  the  orderly  continuance  of  its  action,  that  the  whole 
of  the  great  nervous  centres  may  be  gradually  removed  without  destroying 
this  ;  on  the  other  hand,  it  is  so  directly  under  control  that  not  only  may  irri- 
tation of  a  particular  nerve  running  to  it  bring  its  movement  to  an  instan- 
taneous stop,  but  that  even,  as  long  as  the  connections  are  intact,  the  same 
result  may  follow  reflexly  from  a  stimulus  applied  to  a  centripetal  nerve.  It 
has  shown,  further,  that  the  bloodvessels,  veins  as  well  as  arteries,  are  under 
a  control  so  closely  resembling  this,  that  it  may  be  brought  into  action  by 
the  same  stimulus  ;  as,  indeed,  might  have  been  presupposed  from  the  close 
resemblance  which  the  vessels  present  to  the  heart,  in  their  first  development. 
For  whether  the  history  of  the  individual  or  of  the  race  be  contemplated,  in 
the  one  as  in  the  other,  at  its  first  origin,  the  circulatory  apparatus  is  uniform 
and  simple  in  structure  and  relations ;  only  with  increasing  size  and  com- 
plexity of  other  parts  of  the  bod}r,  in  accordance  with  the  ordinary  principles 
of  the  division  of  labor,  does  it  become  itself  so  complex  that  at  length  some 
divisions  attain  such  a  degree  of  specialization  that  they  are  usually  thought 
of  and  studied  as  if  they  were  independent  and  distinct  from  the  rest.  It  is 
true  that  this  similarity  in  nerve  control  does  not  seem  at  first  sight  so  cical- 
as it  might  be ;  for,  according  to  general  statements,  the  vasomotor  system  is 
not  automatic  and  not  distinct  from  the  central  nervous  system,  but  reflex  and 
situated  in  the  medulla  oblongata,  with  a  prolongation,  as  experiment  has. 
recently  shown,  down  the  spinal  cord ;  but  that  the  power  of  independence, 
comparable  to  that  possessed  by  the  heart,  is  still  retained,  though,  perhaps, 
dormant  and  subordinated,  is  shown  by  experiments  in  which  the  whole 
vasomotor  supply  of  some  part  of  the  body  has  been  cut  oh1,  permanently  ;  at 
first,  the  vessels  dilate  passively,  and  remain  in  this  condition  for  some  days, 
perhaps  even  weeks  ;  but  then  they  gradually  recover  their  tone,  and  can  con- 
tract and  dilate  just  as  before,  but  now,  of  course,  only  in  response  to  local 
stimuli. 

It  may  be,  to  use  the  language  of  teleology,  that  for  the  convenience  of  the 
rest  of  the  organism  the  nerve  centres  that  control  the  vessels,  in  place  of 


366  shock. 

being  widely  scattered  all  over  the  body  as  they  would  have  to  be  if  they 
were  placed  on  the  walls  of  their  own  vessels  (as  in  the*  case  of  the  heart), 
have  been  gathered  together  into  one  group  and  placed  centrally,  still,  how- 
ever, leaving  throughout  the  body  some  trace  of  independent  control,  or  at 
least  some  power  of  developing  it.  ISTor  is  this  the  only  way  in  which  the 
vasomotor  centre  maybe  compared  with  the  cardiac  ganglia,  seemingly  so 
unlike:  for  just  as  the  latter  maybe  inhibited  through  some  special  nerve, 
either  by  direct  irritation  or  reflexly,  so  also  may  the  former,  except  that, 
from  its  central  position,  no  other  than  a  reflex  path  can  be  known.  And 
thus  the  broad  principle  may  be  admitted,  as  a  general  statement,  that  the 
heart  and  the  vessels  are  but  co-ordinate  parts  of  one  system,  and  may  be 
simultaneously  influenced  in  the  same  direction  by  a  single  stimulus ;  and 
that  while  Travers  regarded  shock  as  the  result  of  nerve  action  on  the  heart 
alone,  there  is  nothing  in  the  physiology  of  the  circulation  that  would  pre- 
clude the  posibility  of  a  much  more  general  effect  on  vessels  and  heart 
together. 

But  this  is  by  no  means  all  that  the  subject  of  shock  owes  to  the  recent 
extension  of  physiological  inquiry :  it  is  not  enough  that  the  action  of  the 
heart  and  the  tone  of  the  vessels  (on  which,  with  the  resistance  of  the  capil- 
laries, depends  the  blood  pressure),  may  be  suspended  by  the  direct  or  reflex 
irritation  of  certain  nerves ;  it  has  been  shown  in  the  clearest  manner  that 
this  result  with  all  its  consequences  may  follow  distant,  external  injury ;  and 
external  injury  moreover  of  that  peculiar  form  which  is  more  likely  than  any 
other  to  cause  shock — abdominal  contusion.  This  was  shown  by  Professor 
Goltz,1  of  Strasbourg,  by  a  remarkable  experiment : — 

A  frog  was  taken  and  suspended  in  a  vertical  position,  with  the  legs  downwards, 
and  the  heart  exposed.  After  waiting  a  short  time,  till  the  beats  were  fairly  regular 
and  sent  the  usual  amount  of  blood  into  the  aorta,  the  frog's  intestines  (or  the  surface 
of  the  abdomen)  were  struck  with  some  violence,  and  the  result  on  the  action  of  the 
heart  and  on  its  blood-supply  noted.  It  was  found  at  once  that  the  heart  had  stopped; 
the  irritation  had  been  carried  up  to  the  medulla  oblongata,  and  reflected  thence  down 
the  vagus.  After  a  little  while,  the  heart  seemed  to  recover  and  began  to  pulsate 
again.  But  there  was  a  very  remarkable  difference  between  its  appearance  now  and 
its  appearance  before  the  blow  had  been  given.  Instead  of  becoming  filled  with  blood 
during  each  diastole,  and  assuming  a  deep  red  color  in  consequence,  it  remained  quite 
pale  and  empty,  and,  although  it  contracted  vigorously,  the  circulation  remained 
stopped,  for  the  heart  had  no  blood  to  propel.  The  cause  of  this  was  not  far  to  seek  : 
the  frog  was  hanging  with  its  legs  downwards,  and  the  upper  part  of  the  vena  cava  was 
empty ;  the  veins  of  the  intestines,  generally  kept  in  a  state  of  semi-contraction  by  the 
vasomotor  nerves,  had  become  relaxed,  and  the  blood  which  would  have  filled  them 
completely  up  to  the  heart  was  not  sufficient,  so  that  they  were  only  halt  full.  Not 
only  had  the  inhibitory  nerves  of  the  heart  been  called  into  activity,  but.  that  also 
which  regulates  in  a  similar  manner  the  vasomotor  centre;  for  this  result  did  not  fol- 
low when  the  animal  was  fully  under  the  influence  of  an  anaesthetic,  or  when  the  vagi 
or  splanchnics  had  been  interrupted.  In  the  frog,  recovery  followed  as  soon  as  it  had 
been  placed  in  :i  horizontal  position,  so  that  the  blood  could  reach  the  heart  again  ;  in 
man,  the  stoppage  of  the  heart  in  diastole  would  be  instantaneously  fatal  ;  its  weakened 
action,  and  the  dilatation  of  the  abdominal  vessels,  allowing  the  accumulation  of  such 
an  amount  of  blood — all  really  as  much  withdrawn  for  the  time  from  the  general  cir- 
culation as  if  there  had  been  actual  hemorrhage — would  lower  the  general  arterial 
pressure,  and  cause  the  symptoms  of  shock. 

There  can  be  no  doubt  that  experiments  such  as  these,  which  do  not  vary 
in  the  bands  of  physiologists,  have  thrown  a  flood  of  light  upon  much  that 
before  was  mere  conjecture.     The  suggestions  of  Travers  and  others,  that 

1  Virchow's  Archiv,  xxvi.  and  xxix. 


PATHOLOGY    OF    SHOCK.  367 

such  phenomena  as  arc  presented  in  shock  can  only  be  produced  by  the  sus- 
pension of  the  nervous  power  manifesting  itself  through  the  circulation,  have 
found  their  clearest  proof  in  the  facts  of  physiology  ;  and  it  may  be  taken  as 
demonstrated  beyond  dispute,  that  in  shock  there  is  a  reflex  paralysis  of  the 
heart  and  the  abdominal  .vessels.  There  are  facts,  however,  which  show  that 
its  action  cannot  be  limited  to  these  alone,  but  must,  as  might  be  expected 
from  what  has  been  said  above,  be  extended  over  the  whole  vascular  system, 
if  not  even,  as  Brown-Sequard  has  suggested,  over  the  relation  that  exists 
normally  between  the  blood  in  the  capillaries  and  the  tissues  around  them. 
For  the  symptoms  of  shock  are  not  identical  with  those  of  hemorrhage,  as 
under  these  circumstances  they  probably  would  be;  and,  although  dilatation 
of  the  abdominal  vessels  leading  to  passive  congestion  has  been  noticed  (as, 
for  example,  occasionally  during  ovariotomy),  it  does  not  reach,  if  we  may 
trust  post-mortem  records  of  fatal  cases,  that  extreme  degree  necessary  to 
account  for  the  symptoms.  Further,  Tappeiner1  has  shown,  by  ligaturing 
the  portal  vein  and  then  estimating  the  amount  of  blood  contained  in  its 
radicles,  that  even  in  mammals,  such  as  rabbits,  with  relatively  large  abdo- 
minal viscera,  contrarily  to  the  generally  received  opinion,  all  the  vessels  of 
the  abdomen,  veins  and  arteries  together,  are  not  of  sufficient  capacity  to  hold 
more  than  sixteen  per  cent,  of  the  total  amount  of  blood  in  the  animal's  body 
— a  quantity,  as  long  as  the  other  bloodvessels  preserve  their  innervation 
intact,  quite  unable  to  cause  such  a  loss  of  pressure  ;  for  Midler2  demonstrated 
that,  as  long  as  the  vasomotor  nerves  retained  their  power,  the  total  amount 
of  circulating  blood  might  be  halved  or  doubled  without  producing  any 
appreciable-  difference.  The  same  result  is  arrived  at  after  section  of  the 
splanchnic  nerves  on  both  sides:  by  doing  this,  all  the  vessels  of  the  abdo- 
minal viscera  are  completely  cut  off  from  their  vasomotor  nerves,  and  dis- 
tended to  the  utmost  by  the  blood  stagnating  in  them  (for  it  does  not  seem 
likely  that  active  dilatation  can  ever  take  place;  the  nerve-supply  is  doubt- 
ful, and  the  muscular  mechanism  in  the  walls  unknown) ;  yet  by  actual 
measurement,  with  a  manometer,  of  the  arterial  tension  after  this  has  been 
done,  it  is  found  that  the  fall  is  never  equal  to,  and  in  the  majority  of  cases 
not  half  as  great  as,  that  which  must  occur  in  a  case  of  hemorrhage  if  the 
symptoms  are  comparable  in  their  severity  to  those  of  an  ordinary  case  of 
shock.3  Indeed,  so  far  is  the  general  arterial  tension  from  falling  below  the 
point  consistent  with  the  maintenance  of  life,  that  animals  in  which  this  has 
been  done  on  both  sides  simultaneously,  have  been  known  to  make  a  thor- 
oughly good  recovery — the  local  centres  assuming  the  function  which  the 
medulla  and  spinal  cord  are  no  longer  able  to  carry  out,  and  the  vessels  grad- 
ually resuming  their  calibre  and  regular  tone.4 

From  these  experiments  it  is  legitimate  to  infer  that  something  further  is 
necessary  ;  and  Fischer  is  probably  correct  in  stating  that  in  shock  there  is 
paralysis  of  the  whole  vasomotor  system,  that  of  the  splanchnics  being,  on 
account  of  their  peculiar  distribution,  the  most  marked.  As  the  vessels  have 
been  shown  to  be  all  under  the  control  of  the  same  nerve-centre,  it  must  be 
admitted  that  there  is  nothing  improbable  in  this ;  and  it  certainly  affords  a 
reasonable  explanation  (through  the  stagnation  of  venous  blood  in  the  capil- 
laries) of  the  lividity  of  the  skin  and  all  the  visible  parts,  so  different  from 
the  waxy  pallor  of  hemorrhage.  There  are  a  few  facts  that  point  to  the 
possibility  in  some  cases  of  different  parts  of  the  vascular  system  being 
affected  in  different  degrees.  Goltz,  in  his  experiments,  sometimes  found 
that  the  heart  was  very  much  more  interfered  with  than  the  vessels ;  some- 

1  Tappeiner,  Ludwiei's  Arbeiten,  Leipzig,  1872.  2  Miiller,  Ludwig's  Arbeiten,  1874. 

8  Tappeiner,  loc.  cit.  4  Asp,  Ludwig's  Arbeiten,  1867. 


368  shock. 

times,  with  conditions  apparently  similar,  the  reverse  ;  and,  perhaps,  some- 
thing of  this  kind  may  be  suggested  as  an  explanation  of  the  extreme  con- 
gestion of  the  portion  of  intestine  above  a  strangulation,  as  compared  with 
the  condition  of  that  below. 

It  is  to  be  feared  that  this  theory,  which  has  been  adopted  in  its 
entirety  by  Fischer,  and  which  must  be  regarded  as  an  enormous  advance 
upon  all  previous  views,  cannot  yet  be  admitted  as  thoroughly  sufficient.  It 
cannot  but  be  considered  as  most  strange  that  injuries  to  the  cervical  spinal 
cord  are  not  invariably  followed  by  instant  death  ;  for  while  the  heart  suffers 
under  the  general  shock,  there  is  absolute  paralysis  of  every  vasomotor 
nerve  in  the  body,  head  and-  upper  extremities  included  ;  yet,  though  the 
shock  is  sometimes  undeniably  severe,  it  is  certainly  not  in  the  majority  of 
fatal  cases  the  cause  of  death ;  and  there  are  several  instances  on  record  of 
continuance  of  life  with  complete  paralysis  of  motion  and  sensation  in  all 
parts  below  the  seat  of  injury,  the  normal  arterial  tension  being  restored  and 
maintained  as  usual  by  means  of  the  peripheral  mechanism,  and  perhaps  of 
that  portion  of  the  great  centre  contained  in  the  spinal  cord.  Nor  can  it  be 
argued  that  the  vascular  tension  is  at  once  restored,  even  in  part,  by  this  por- 
tion of  the  vasomotor  centre  in  the  cord  below  the  seat  of  injury;  for  it  is 
well  known  from  experiments  on  animals  that,  even  after  simple  section 
through  the  spinal  cord,  no  reflex  movement  of  any  kind  can  be  excited  for 
some  time  in  any  nerve  that  is  dependent  on  the  distal,  severed  portion. 
There  is,  further,  an  observation  made  by  Weir  Mitchell1  to  the  etfect  that  in 
the  variety  of  the  cerebral  phenomena  presented  by  eases  of  shock,  there  is 
evidence  of  a  change,  less  constant  in  its  effects  than  would  be  that  of  mere 
alteration  in  the  amount  of  blood. 

Nor  is  there  any  improbability  in  the  suggestion  that  the  peculiar  power 
of  inhibition,  in  which,  as  far  as  is  known,  all  nerve  structures  share,  and 
which  is  probably  brought  into  play  during  the  co-ordination  of  every  nerve 
impulse,  instead  of  only  indirectly  causing  the  symptoms  of  shock  through 
its  action  on  the  vascular  system,  may  be  the  direct  and  immediate  agent 
influencing  the  nerves  that  govern  sensation,  motion,  and  volition,  as  much 
as  those  that  control  the  walls  of  the  bloodvessels.  It  has  been  shown  beyond 
the  shadow  of  doubt  that,  as  a  consequence  of  injury,  the  molecular  motion 
which  constitutes  nerve  force  may  be  interfered  with,  perhaps  even  inter- 
rupted, in  certain  centres  that  control  the  heart  and  the  vascular  system ; 
may  it  not  be  that  the  paralysis  of  motion  and  sensation,  and  the  impair- 
ment of  reflex  action,  instead  of  being  merely  secondary  effects  produced 
through  the  agency  of  the  circulation,  are  also  due,  wholly  or  in  part,  to  a 
similar  interference  with  the  molecular  motion  in  other  centres?  and  that 
shock  is  to  be  regarded  as  an  extreme  and  general  manifestation  of  that  inhi- 
bition, with  the  power  of  which,  as  regards  a  lew  organs,  physiology  has 
made  us  acquainted?  It  is  highly  probable  that  many  of  the  so-to-speak 
accessory  consequences  of  injuries,  the  immediate  dependence  of  which  on  the 
actual  damage  is  not  apparent,  are  due  to  some  cause  closely  analogous  to 
this;  and  especially  is  this  true  of  injuries  to  the  nerve  centres,  and  of  conse- 
quences thai  make  their  appearance  at  once  and  gradually  disappear. 

A  powerful  stimulus  applied  to  a  sensory  nerve  can  entirely  obHterate  a 
slighter  one.  After  laving  open  the  spinal  canal,  irritation  of  the  posterior 
roots  is  for  some  time  followed  by  no  result.  After  section  through  the 
Spinal  cord,  reflex  phenomena  are  not  witnessed  till  the  inhibitory  influence 
is  wearing  off ;  and  if  when  these  have  returned,  and  the  animal  has  recov- 
ered as  far  as  is  consistent  with   the  continuance  of  paraplegia,  a  second  sec- 

1   New  York  Medical  Journal,  18G6. 


PROGNOSIS  OF  SHOCK — REACTION.  369 

tion  is  carried  through,  higher  up,  only  those  parts  of  the  body  are  affected 
which  are  indebted  for  their  innervation  to  the  portion  of  cord  above  the 
original  section — showing  that  it  is  only  along  nerve  paths  that  the  influence 
of  shock  can  make  itself  felt ;  the  lower  limbs,  in  an  experiment  of  this 
kind,1  severed  from  all  nerve  connection  with  the  part  of  the  cord  that  has 
sustained  the  most  recent  injury,  manifest  no  diminution  whatever  of  reflex 
excitability,  none  of  the  symptoms  of  shock,  only  a  contraction  of  their  blood- 
vessels, secondary  to  and  consequent  on  the  loss  of  pressure  in  the  rest  of  the 
body.  More  recently,  Lewisson2  has  established,  by  means  of  experiments, 
that  in  a  frog  it  is  quite  possible  to  suspend  the  activity  of  the  reflex  centres 
by  the  irritation  of  sensory  nerves  ;  that  if  the  irritation  be  sufficiently  pow- 
erful, this  inhibition  may  be  extended  to  the  voluntary  movements  ;  and  that 
finally,  in  a  rabbit,  by  crushing  the  kidneys,  uterus,  bladder,  or  intestine,  all 
control  over  the  lower  extremities  may  be  abolished,  the  paralyzing  influence 
continuing  for  some  time  after  the  cessation  of  the  irritation,  and  lasting  the 
longer  in  proportion  to  its  violence.  It  is  possible  that  these  results,  of  such 
importance  in  this  question,  may  be  due  to  a  condition  of  spinal  anaemia ; 
some  experiments  of  Brown-Sequard,3  showing  the  contraction  of  the  vessels 
in  the  pia  mater  of  the  cord,  resulting  from  such  an  injury  to  the  abdominal 
viscera  as  passing  a  ligature  round  the  hilus  of  a  kidney,  would  -point  in  this 
direction ;  but  the  result  is  not  one  which  is  material  to  the  cause  at  issue, 
and  the  experiments  are  of  such  difficulty  and  have  been  repeated  by  subse- 
quent observers  with  such  slight  success,  that  Vulpian  at  least  considers  it 
more  than  doubtful  if  the  conclusions  are  justified.  It  remains  that,  as  a 
result  of  injury,  either  directly  involving  the  nervous  centres  or  indirectly 
influencing  them  by  the  effect  produced  on  distant  organs  (especially  those  of 
the  abdomen),  there  may  be  produced  in  animals  a  condition  which,  after  due 
allowance  has  been  made  for  the  difference  in  cerebral  organization,  cannot 
be  distinguished  in  many  of  its  features  from  that  known  as  shock ;  and 
which  not  only  finds  in  physiology  its  nearest  and  best  known  parallel  in  the 
effect  produced  on  the  circulation  by  the  irritation,  direct  or  reflex,  of  certain 
nerves,  but  actually  presents  this  effect  as  one  of  its  best  marked  symptoms. 
In  short,  shock  is  an  example  of  reflex  paralysis  in  the  strictest  and  narrowest 
sense  of  the  term — a  reflex  inhibition,  probably  in  the  majority  of  cases  gene- 
ral, affecting  all  the  functions  of  the  nervous  system,  and  not  limited  to  the 
heart  and  vessels  only. 


Prognosis  of  Shock. — Reaction. 

_  Shock  may  be  fatal  within  the  space  of  a  few  seconds,  as  in  the  example 
given  above,  or,  as  frequently  happens  in  severe  and  extensive  injuries,  the 
patient  may  sink  gradually,  after  a  longer  or  shorter  time,  without  any  at- 
tempt at  recovery.  Even  if  reaction  does  set  in  within  a  reasonable  period, 
and  the  longer  the  delay  the  greater  the  danger,  all  fear  from  this  cause  must 
not  be  laid  aside;  sometimes,  it  is  true,  recovery  is  gradual  and  uninter- 
rupted ;  more  often  its  course  is  much  less  uniform,  fluctuations  more  or  less 
alarming  often  being  present ;  and  sometimes,  when  all  seems  progressing 
favorably,  the  heart  fails  suddenly  as  if  its  reserve  of  strength  had  "become 
exhausted,  and  the  patient  dies  in  very  much  the  same  way  as  in  secondary 
asphyxia. 

It  is  difficult  to  define  the  precise  moment  when  reaction  commences. 

1  Goltz,  Pfliiger's  Archiv,  1875.  Quoted  by  Fischer,  loc.  cit. 

3  Archives  Generales  de  Medecine,  5e  serie,  tome  viii.  lSSti. 

vol.  i. — 24 


370  SHOCK. 

Furneaux  Jordan  wouia  place  it  very  early,  believing  that  there  is  in  shock, 
at  first,  a  diminished  frequency  of  pulse  that  soon  passes  off,  giving  place  to 
rapid  and  irregular  action.  The  most  satisfactory  sign  is  an  increase  of 
strength  in  the  heart's  heat ;  this  soon  leads  to  diminished  rapidity  and  more 
regular  rhythm.  Vomiting,  especially  if  the  stomach  is  full,  is  very  com- 
mon ;  but  it  should  not  continue,  and  must  not  be  confounded  with  that  sign 
of  the  persistence  of  shock,  intense  irritability  of  the  stomach  allowing 
nothing  to  remain  there.  Then  the  respiration  becomes  deeper  and  more 
even,  the  face  loses  its  livid  pallor,  the  countenance  begins  to  show  some  ex- 
pression, and  the  limbs,  instead  of  lying  helpless,  are  moved  to  more  com- 
fortable positions ;  but  it  is  a  long  time,  even  if  no  fever  sets  in,  before  the 
will  acquires  its  accustomed  power;  and  it  maybe  as  much  from  this  as 
from  anything  else  that  prolonged  retention  of  urine  is  so  often  met  with. 
In  general,  even  if  there  has  been  no  wound,  reaction  is  marked  by  a  certain 
amount  of  fever  ;  the  skin  becomes  hot  and  dry,  the  face  flushed,  the  urine 
scanty  and  high  colored,  the  pulse  full  and  bounding,  and  there  is  thirst, 
with  restlessness  and  headache.  Where  shock  after  accidents  or  operations 
has  been  severe,  there  is  an  attack  of  ordinary  traumatic  fever,  varying  with 
the  nature  of  the  accident,  the  method  of  its  treatment,  and  the  constitution 
of  the  patient,  from  a  slight  rise  of  temperature  attended  with  the  ordinary 
sleeplessness  and  constipation,  to  a  condition  of  the  most  extreme  excitement, 
rapidly  running  on  to  fatal  exhaustion — that  form  to  which  Travers  gave 
the  name  of  "  prostration  with  excitement ;"  then  the  languor  that  character- 
ized the  early  stage  passes,  after  a  variable  interval,  into  restlessness,  jactita- 
tion, and  precordial  anxiety  ;  often,  but  not  always,  there  is  delirium  varying 
in  degree  from  occasional  incoherence  to  wild  and  fierce  excitement,  more 
frequently  occurring  and  more  marked  during  the  night ;  at  times  the  con- 
dition is  scarcely  distinguishable  from  that  in  an  ordinary  case  of  Delirium 
Tremens.  Soon  succeed  exhaustion,  marked  by  somnolency  ;  a  profuse  chill 
and  clammy  sweat;  a  haggard  and  livid  aspect;  a  small,  irregular,  or  flutter- 
ing pulse ;  innumerably  rapid,  panting  respirations ;  passive  convulsions, 
hiccough,  and  subsultus  ;  the  stupor  and  stertor  of  apoplex}^  and  death. 

The  question  of  prognosis  must  be  answered  in  each  case  mainly  from  the 
degree  of  the  injury  sustained:  for,  though  shock  is  by  no  means  wholly 
dependent  on  this,  generally,  in  severe  cases,  there  is  either  great  injury  or 
injury  of  some  great  part.  Loss  of  the  power  of  swallowing,  showing  that. 
probably  there  lias  been  inhibition  of  the  glosso-pharyngeal  centre  in  the 
medulla  oblongata,  in  the  immediate  neighborhood  of  other  centres  indis- 
pensable to  the  maintenance  of  life;  and  insensibility  of  the  conjunctiva, 
leading  to  the  conclusion  that  the  fifth  pair  of  nerves  has  become  implicated, 
must  each  of  them  be  regarded  as  of  the  gravest  import.  Any  hemorrhage, 
even  if  slight,  is  a  complication  much  more  dangerous  than  would  at  first  be 
supposed,  owing  to  the  extreme  depression  of  arterial  tension  already  exist- 
ing; the  clinical  observation  made  by  Travers,  with  regard  to  the  very 
serious  import  of  the  loss  of  even  a  small  amount  of  blood  in  syncope  or 
shock,  luis  been  demonstrated  and  explained  by  the  physiological  experimen is 
of  Tappeiner.  The  longer  reaction  is  delayed,  and  the  more  incomplete  and 
fluctuating  it  is,  the  more  hopeless  the  case.  Still,  even  in  the  worst,  some- 
times recovery  docs  take  place,  against  all  hope,  when  the  patient  has  lingered 
hours  and  even  days  in  an  almost  lifeless  state.  Among  conditions  usually 
regarded  as  unfavorable,  musl  be  placed  either  extreme  of  life ;  and,  of  the. 
two,  advanced  age  as  the  most  threatening;  and  similarly  that  condition  of 
premature  degeneration  of  which  the  abdominal  viscera  especially  present 
such  frequent  examples. 

In  the  case  of  operations,  prognosis  may  often  be  rendered  much  more  easy 


TREATMENT    OF    SHOCK.  371 

and  certain  b}7  a  careful,  previous  study  of  a  patient's  habit  of  thought  and 
feeling ;  whether  he  is  hopeful  and  cheerful,  looking  forward  to  speedy 
recovery,  or  downcast  and  despondent,  with  a  dogged  conviction  that  cannot 
be  reasoned  with  that  things  will  not  go  well — a  conviction  in  itself  appa- 
rently enough  to  cause  the  worst  result.  For  there  are  too  many  recorded 
cases  of  death  after  slight  operations,  and  after  perfectly  natural  labors,  and 
even  on  a  fixed  day,  for  there  to  be  any  longer  doubt  as  to  the  very  grave 
addition  that  has  to  be  made  to  the  unfavorable  features  of  a  case,  when  the 
patient  entertains  a  fixed  idea  that  recovery  is  impossible.  There  are  at  least 
two  distinct  forms  of  mental  influence  which  operate  powerfully  upon  the 
result.  The  first  is  either  the  buoyancy  produced  by  hope,  and  a  firm  belief 
in  a  successful  issue  ;  or  the  depression  produced  by  despondency,  and  a  rooted 
conviction  that  the  result  will  be  fatal.  The  second  is  either  a  calm  and 
equable  disposition,  patient  and  enduring ;  or  a  peevish  and  irritable  temper, 
restless  and  complaining.  The  former  of  these  is  usually  influenced  by  age, 
the  latter  by  sex.  The  young  are  the  most  hopeful,  and  women,  as  a  rule, 
endure  most  patiently.1 


Treatment  of  Shock. 

Though  it  does  not  seem  probable,  in  the  present  state  of  knowledge,  that 
shock  can  be  altogether  prevented,  especially  when  regard  is  had  to  the 
fortunately  exceptional  cases  of  very  sudden  death,  yet  undoubtedly,  as  far 
as  operations  are  concerned,  its  severity  may  be  in  some  measure  diminished ; 
and  not  only  in  cases  of  disease  of  long  standing,  in  which  amputation  or 
excision  may  be  required,  and  in  which  the  state  of  health  of  the  patient  may 
have  been  already  much  modified  by  the  confinement  or  the  other  conditions 
to  which  he  has  been  subjected,  but  also  in  such  operations  as  the  removal  of 
tumors,  or  lithotomy,  when  the  patient,  as  far  as  can  be  ascertained,  is  in  a 
condition  of  complete  health,  and  no  part  of  the  body  through  long-continued 
suffering  has  come  to  bear  an  altered  relation  to  the  rest.  The  care  taken  in 
the  preparation  of  a  patient,  accustoming  him  to  altered  rules  and  conditions 
of  life,  and  rendering  him  familiar  with  persons  and  things  about  him,  is 
labor  well  spent,  even  if  light ;  and  there  is  not  a  little  in  the  conduct  of  the 
operation  itself — the  restraint  of  hemorrhage  and  the  avoidance  of  cold  or 
exposure  while  the  patient  is  on  the  table,  and  of  unnecessary  delay  during 
its  performance.  How  far  anaesthetics  are  of  use  in  the  prevention  of  shock, 
is  a  question  that  had  best  be  considered  with  that  of  their  advisability  during 
its  continuance.  [Easley  and  McGuire  recommend  large  doses  of  quinia, 
before  an  operation,  as  a  means  of  preventing  shock.] 

In  the  treatment  of  a  person  suffering  from  severe  shock  after  injury,  the 
first  care  should  be  to  loosen  everything  around  the  neck  or  chest,  that  can  in  any 
way  impede  respiration,  and  to  place  the  body  in  a  recumbent  position,  with 
the  head  as  low  as  possible ;  even  a  pillow  is  not  always  advisable.  Of  course, 
any  source  of  hemorrhage  should  be  at  once  investigated,  but,  during  shock 
at  least,  bleeding  is  not  of  common  occurrence.  And,  above  all  tilings,  it  is 
necessary  in  every  way  to  maintain  the  temjieraturc  of  the  body  as  near  the 
normal  degree  as  possible :  as  the  circulation  fails,  the  temperature  falls ;  the 
bed  and  the  room  should  be  warmed,  warm  blankets  and  hot  bottles  should 
be  placed  around  the  patient,  and  the  extremities  should  be  well  rubbed.  It 
has  even  been  recommended  (and  carried  out  successfully  by  Hunter,  of 
Philadelphia)  that  patients  when  suffering  from  shock  should  be  placed  in  a 

1  Savory,  loc.  cit. 


372  shock. 

hot  bath,  beginning  at  a  temperature  of  98°  F.,  and  gradually  increasing  it  to 
110°  F.  By  leaving  a  patient  in  a  batli  in  this  way  for  a  quarter  of  an  hour, 
the  temperature  of  the  body  has  been  raised  from  96°  F.  to  98°. 5  F.,  the 
respirations  reduced  in  number  from  36  to  20  in  the  minute,  and  the  cold  and 
clammy  skin  rendered  warm  and  dry.  When  the  heart  shows  signs  of  foiling, 
external  heat  is  sometimes  of  further  use  in  the  form  of  flannels  or  sponges 
wrung  out  of  water  as  hot  as  can  be  borne,  and  applied  to  the  cardiac  and 
epigastric  regions.  Counter-irritation  more  vigorous  than  this  is  of  question- 
able service,  though  there  can  be  no  doubt  that  sinapisms  and  blisters  applied 
to  the  extremities  can,  by  the  irritation  of  sensory  nerves,  cause  a  slight 
elevation  of  the  general  blood-pressure.  In  persistent  vomiting,  a  mustard- 
plaster  may  sometimes  be  applied,  with  very  good  effect,  to  the  pit  of  the 
stomach. 

The  use  of  stimulants  cannot  be  avoided  in  a  severe  case  of  shock.  It  is 
quite  true  that  a  patient  may  recover  without  their  employment,  but  no  one 
who  has  ever  seen  the  color  come  back  rapidly  to  a  patient's  face,  or  felt  the 
pulse  beat  stronger  at  the  wrist,  after  a  small  quantity  of  brandy  has  been 
swallowed,  will  hesitate  again  as  to  the  propriety  of  their  use.  The  quan- 
tity must  be  judged  of  individually  in  each  case,  but  need  never  be  great;  if 
reaction  is  coming  on  fairly,  and  continuing  evenly,  very  little  is  required ; 
if  the  reverse  be  the  ease,  and  one  or  two  ounces  of  brandy  produce  no  effect, 
it  is  probable  that  it  is  not  being  absorbed  by  the  stomach,  and  the  ingestion 
of  a  further  quantity  would  only  result  in  causing  vomiting.  In  this  case, 
or  where  the  power  of  swallowing  has  been  lost,  enemata  of  small  volume 
containing  brandy  may  be  tried,  or  subcutaneous  injections  of  brandy  or  of 
ether,1  but  usually,  it  must  be  confessed,  with  little  hope.  Afterwards,  when 
reaction  has  fairly  set  in,  there  is  no  proof  that  stimulants  are  of  much  avail ; 
nourishment  of  a  more  lasting  character  is  required,  but  a  very  careful  watch 
should  be  kept  on  the  pulse,  and  a  small  quantity  of  brandy  administered 
whenever  this  shows  signs  of  failing,  and  repeated  every  half  hour  if  need  be. 
Opium,  in  some  form  or  another,  is  nearly  always  required  to  allay  pain  and 
to  procure  rest ;  if  this  can  be  obtained,  nourishment  need  not  be  pressed  just 
at  first.  Opium  seems  of  equal  service,  however  given :  by  the  mouth,  by 
the  rectum,  or  hypodermically  ;  if  it  cause  sickness  when  injected  under  the 
skin,  it  may  be  combined  with  atropia  ;  or  it  may  be  given  by  the  mouth, 
the  required  quantity,  in  form  of  the  liquor  opii  sedativus,  undiluted,  being 
placed  upon  the  tongue;  or  sometimes  a  freshly  made  pill  of  crude  opium  will 
answer  the  purpose  when  nothing  else-  is  successful. 

It  must  be  very  seldom  that  a  case  presents  such  peculiar  features  that 
artificial  respiration  would  be  of  any  serviee ;  it  is  nearly  always  the  heart  that 
gives  out  first,  and  death  from  asphyxia,  due  to  the  lungs  failing  to  act, 
must  be  very  rare.  Transfusion  has  been  tried  in  a  sufficient  number  of 
cases  f<>  prove  its  futility,  as  long  as  shock  is  unaccompanied  by  serious 
hemorrhage;  when  Ibis  is  the  case,  the  question  rests  on  altogether  different 
grounds.  EJp  to  a  certain  point,  simple  hemorrhage  has  scarcely  any  effect 
upon  the  blood-pressure,  the  vasomotor  nerves  causing  the  vessels  to  contract 
in  proportion  to  the  loss  of  the  circulating  fluid;  but  beyond  that  pointthe 
compensation  fails,  and  the  pressure  talis  with  great  suddenness.  If,  iu  a 
case  of  this  nature,  uncomplicated,  transfusion  be  resorted  to  at  this  critical 

'  Verneuil  (Journal  de  Med.  et  de  Chir.  Pratiques,  Mars,  1877)  recommends  subcutaneous 
injei  i  iona  of  ether,  L5  minims,  repeated  in  mi  hour's  time  if  required,  stating  that  he  lias  seen 
very  great  benefit  derived  from  it.  [The  editor  is  oonfident  that  he  has  saved  life,  in  cases  of 
severe  shook,  by  the  hypodermic  use  of  ether;  it.  may  be  administered  very  freely,  a  syringeful 

(about  30  minims)  being  injected  every  liv •  ten  minutes  until  the  patient  is  able  to  swallow, 

when  carbonate  of  ammonium,  5  grains  every  half-hour  by  the  mouth,  may  be  substituted.] 


TREATMENT    OF    SHOCK.  373 

moment,  a  relatively  small  amount  of  blood  may  save  the  patient's  life.  But 
in  shock,  in  which  the  vasomotor  mechanism  is  almost,  if  not  completely 
paralyzed,  and  in  which  the  most  serious  symptoms,  even  death  itself,  may 
occur  without  the  loss  of  a  single  drop  of  blood,  the  question  is  totally  dif- 
ferent. Injection  of  more  blood  only  increases  the  amount  stagnating,  and 
does  nothing  to  raise  the  pressure.  The  limits  within  which  vascular  tension 
is  independent  of  the  amount  of  blood,  are  very  wide. 

It  has  been  suggested  that  in  cases  where  the  external  jugular  veins  stand 
out  prominently,  and  where  presumably  the  right  side  of  the  heart  is  full  of 
blood,  venesection  would  be  of  some  service,  and  might,  by  relieving  the  dis- 
tension, stimulate  the  heart  to  fresh  action.  But  this  condition  points  to 
asphyxia,  and  not  to  shock;  and  in  the  face  of  the  serious  influence  of  acci- 
dental hemorrhage,  can  scarcely  be  advised.  The  heart  is  distended  because 
it  is  paralyzed;  not  paralyzed  because  it  is  distended. 

The  intravenous  injection  of  ammonia  has  been  tried  in  a  few  cases  with 
sufficient  success  to  warrant  a  repetition  of  the  experiment;  by  this  means 
Penfold1  probably  saved  a  patient  in  extreme  collapse  from  continuous  purg- 
ing; and  Tibbits,2  after  trying  it  unsuccessfully  in  a  case  of  septicaemia,  and 
another  of  hemorrhage,  brought  around  by  its  aid  a  very  severe  case  of  rail- 
way injury,  in  which  the  pulse  at  the  wrist  was  quite  imperceptible,  and  the 
patient  had  already  lost  all  power  of  swallowing.  The  quantity  injected  at 
one  time  should  not  exceed  ten  minims  of  the  liquor  ammonia?  fortior,  and 
care  should  be  taken  not  to  send  it  into  the  subcutaneous  tissue ;  the  degree 
of  dilution  is  not,  according  to  Harford,  material.  [As  pointed  out  by  Dr. 
Richardson,  ammonia,  whether  given  in  this  way  or  by  the  mouth,  both  acts 
as  a  stimulant  and  is  useful  by  maintaining  the  fluidity  of  the  blood,  and  thus 
obviating  the  risk  of  heart-clot — a  pathological  condition  found  in  most  of 
the  cases  of  so-called  "secondary  shock."] 

There  are  three  drugs,  strychnia,  belladonna,  and  digitalis,  the  use  of  which, 
from  their  action  on  the  blood-pressure  and  the  vasomotor  nerves,  has  been 
particularly  recommended  during  the  continuance  of  shock,  in  the  hope  of 
relieving  at  least  one,  and  perhaps  the  most  prominent  symptom.  Of  these 
drugs,  the  last  named  is  perhaps  the  most  hopeful,  from  the  power  which  it 
has  been  shown  to  possess  both  over  the  heart  and  the  arterioles,  diminishing 
the  rapidity  of  contraction  of  the  former,  and  increasing  its  strength,  while  at 
the  same  time  it  stimulates  the  muscular  walls  of  the  latter.  It  has,  indeed, 
been  employed  by  Dr.  Wilks3  for  this  purpose,  in  a  case  of  shock  following 
parturition:  the  patient  was  apparently  in  articulo  mortis ;  her  limbs  were 
cold ;  her  body  in  a  state  of  deathly,  clammy  sweat ;  the  face  was  livid ;  no 
pulse  was  to  be  felt  at  the  wrist ;  and  a  mere  fluttering  was  heard  when  the 
ear  was  placed  over  the  region  of  the  heart.  Brandy  and  ether  had  been  em- 
ployed without  any  good  effect,  and,  as  dissolution  was  imminent,  it  was 
determined  to  try  digitalis.  Half-drachm  doses  of  the  tincture  were  given 
every  hour;  after  four  doses  reaction  set  in,  and  after  seven,  complete  recovery 
"began.  Dr.  Lauder  Brunton  remarks  on  this  case  that  a  consideration  of 
the  encouraging  results  obtained  can  hardly  fail  to  gain  for  digitalis  a  much 
more  extensive  application  in  cases  of  shock  than  it  has  hitherto  received. 
\  et  this  mode  of  treatment  does  not  seem  to  have  been  resorted  to  by  others. 
Strychnia,  which,  like  digitalis,  may  be  given  either  by  the  mouth  or  sub- 
cutaneously,  in  cases  of  this  kind,  derives  its  chief  recommendation  from  the 
result  of  experiments  by  Mayer4  and  Prokop  Rokitanski,5  showing  the  power 

1  Australian  Medical  Journal,  January,  1873.  2  Med.  Times  and  Gazette,  November,  1872. 

3  Mod.  Times  and  Gazette,  January,  1864. 

4  Med.  Jahrbiicher  d.  k.-k.  Ges.  d.  Aertze  zu  Wien,  1872. 

5  Quoted  by  Brunton,  Saiut  Bartholomew's  Hospital  Reports.  1S79. 


374  shock. 

it  possesses  over  botli  the  vasomotor  and  the  respiratory  centres  in  the  me- 
dulla oblongata  and  spinal  cord;  but  actually,  in  the  only  case  in  which  I  am 
aware  that  it  has  been  tried,  the  result  was  not  satisfactory.  Belladonna,1 
too,  in  very  small,  repeated  doses,  acting  as  a  stimulant  to  the  vasomotor  sys- 
tem, is  perhaps  worthy  of  a  trial. 

With  regard  to  the  employment  of  an  anaesthetic  when  an  operation  is 
required  in  a  case  of  shock,  and  still  more  with  regard  to  the  choice  of  the  par- 
ticular substance  to  be  used,  there  is  very  great  diversity  of  opinion.  On  the 
whole,  it  may  be  said  that  the  balance  is  at  present  decidedly  in  favor  of  the 
administration  of  these  agents,  and  of  ether  rather  than  of  chloroform.  It  is 
true,  as  Fischer  has  remarked,  that  patients  seldom  feel  to  any  extent,  and 
that  sometimes,  when  no  anaesthetic  is  administered,  the  pulse  improves  even 
during  the  operation ;  but  the  former  statement  is  not  worth  much  as  an 
argument;  and  the  latter  is  of  no  avail  against  the  employment  of  ether. 
Indeed,  the  only  objection  that  can  be  urged  against  the  latter,  is  that  in  the 
ordinary  methods  of  administering  it,  the  supply  of  oxygen  to  the  patient  is 
too  much  interfered  with.  Chloroform,  which  is  used,  perhaps,  less  than  it 
was,  but  is  still  preferred  by  some  experienced  administrators  in  these  cases, 
is  undoubtedly,  when  pressed  at  all  far,  an  exceedingly  dangerous  agent ;  a 
minimum  quantity  is  required  to  anaesthetize  the  patient,  and  only  a  drop  or 
two  occasionally  to  maintain  the  influence  of  the  drug ;  anything  over  this, 
quite  abolishing  the  action  of  the  cerebral  hemispheres,  will  be  probably  dis- 
astrous. For,  as  Brunton2  has  pointed  out,  the  violent  irritation  of  a  sensory 
nerve  affects  the  heart  refiexly,  but  compensates  itself  by  causing  the  small 
vessels  to  contract,  and  so  raise  the  blood-pressure ;  if  the  quantity  given  is 
sufficient  to  do  away  with  sensation  completely,  the  compensating  action  is 
lost,  and  there  is  danger;  if  the  chloroform  is  pushed  further  still,  the  reflex 
centre  in  the  medulla  inhibiting  the  heart  becomes  .affected  equally  with  the 
cerebral  hemispheres,  and  the  danger  is  past;  and  Brunton  cites  Syme  as 
always  having  used  chloroform  with  a  free  hand.  But  in  shock  there  is  cer- 
tainly no  need  to  proceed  as  far  as  this.  A  great  deal  has  been  said  about 
the  choice  of  the  time  for  performing  an  operation ;  whether  to  operate  at 
once,  wait  till  reaction  is  commencing,  or  until  it  has  fully  set  in  ?  Xo  doubt 
each  case  must  be  judged  on  its  merits,  but  still  some  general  rules  may  be 
laid  down.  The  main  guide,  of  course,  is  the  severity  of  the  shock  sustained, 
as  evidenced  by  the  patient's  pulse  and  general  condition.  If  it  is  not  severe, 
it  need  scarcely  be  regarded ;  if  so  grave  that  it  is  questionable  whether  react 
tion  can  set  in,  every  means  should  be  tried  to  bring  the  patient  around  before 
operation  is  attempted;  in  all  other  cases,  it  is  probable  that  Guthrie's  advice 
will  be  admitted  by  most  at  the  present  day  to  be  the  most  reasonable:  wait 
two,  tour,  or  six  hours  if  need  be,  till  the  pulse  is  beginning  to  regain  some  of 
its  strength,  and  till  the  patient  is  recovering  sufficiently  to  become  conscious 
ofpain.  [Some  information  maybe  gained  by  observing  the  temperature. 
1 1'  this  be  below  90°  F.  (35°. 5  C,  Redard),  no  operation  should,  as  a  rule,  be 
performed.  J 

Fatty  Embolism. 

Tn  discussing  the  symptoms  of  shock,  it  was  mentioned  that  many  of  the 
fatal  cases  Hitherto  ascribed  to  its  influence  must  be  referred  to  some  other 
cause  especially  when  after  an  injury  or  operation  the  patient  continues  to 
present  a  perfectly  satisfactory  condition  for  some  hours  or  even  day's,  and 
then,  more  or  less  suddenly,  is  seized  with  symptoms  indicative  of  some  great 

1  Gasquet,  Practitioner,  May,  1S79.  *  British  Medical  Journal,  December,  1S75. 


FATTY    EMBOLISM.  375 

disturbance,  and  dies.  It  is  not  possible  to  understand  how  any  effect  of 
nerve  influence  that  was  caused  by  injury,  could  remain  for  two  or  even  three 
davs  concealed  so  thoroughly  that  there  should  be  no  suspicion  of  its  exist- 
ence, and  then  manifest  itself  with  such  intensity  and  rapidity  as  to  occasion 
death  within  a  few  hours.  Some  other  explanation  manifestly  is  required 
for  such  cases  as  these  ;  and  within  the  last  few  years  it  has,  so  it  is  believed, 
been  found,  for  many  at  least,  in  what  is  known  as  Fatty  Embolism,  that  is, 
embolism  of  the  small  arteries  in  the  lungs,  and  very  commonly  in  other 
organs,  due  to  minute  drops  of  fluid  fat  which,  having  been  set  free  some- 
where in  the  periphery  (generally  in  connection  with  the  medullary  cavity 
of  bones),  are  carried  into  the  circulation  and  follow  its  ordinary  course. 

It  was  not,  however,  in  connection  with  any  case  of  injury  that  the  exist- 
ence of  fatty  embolism  was  first  discovered ;  for  the  earliest  observation1  on 
record  refers  to  a  case  of  contracted  kidney,  in  which  the  choroidal  vessels 
were  found  to  have  been  plugged  with  particles  of  fat  supposed  to  have  come 
from  an  atheromatous  aorta;  and  in  the  next,2  in  which  after  severe  injury 
to  the  bones  the  pulmonary  vessels  were  loaded  with  fat,  the  significance  of 
the  lesion  was  quite  missed ;  and  when,  shortly  after  this,  Wagner3  made  a 
similar  observation  in  two  fatal  cases  of  pyaemia,  the  suggestion  was  imme- 
diately raised  that  the  fat  was  in  some  connection  with  the  metamorphosis 
of  pus  at  the  periphery,  and  the  development  of  metastatic  abscesses  in  the 
lungs.  Some  experiments,  in  which  the  necessary  conditions  were  not  main- 
tained, served  to  perpetuate  this  view  till  1865,  when  Warner4  published  the 
results  of  forty-eight  cases  in  which  he  had  found  this  lesion  (fifteen  of  these 
being  instances  of  rapid  death  after  severe  injury  to  the  bones  and  soft  parts); 
and  Bosch  demonstrated  by  cinnabar  injections  that;  immediately  after  injury 
to  the  medulla  of  bones,  it  was  possible  for  particles  of  fat  to  enter  the  open 
mouths  of  the  lacerated  veins  and  be  carried  into  the  pulmonary  arterioles, 
causing  embolisms,  without,  however,  necessarily  entailing  abscesses  or  inflam- 
matory disturbance.  From  these  facts,  and  from  experiments  by  Bergmann8 
on  the  intravenous  injection  of  oil,  \Yagner  was  led  to  the  conclusion  that 
the  coexistence  of  fatty  embolism  with  pyaemia  was  merely  accidental ;  and 
since  then  it  has  been  shown  clearly  that  the  very  different  results  to  which 
fatty  embolism  may  lead,  depend  on  whether  it  occurs  after  subcutaneous 
injury,  or  is  due  to  some  disturbance  set  up  in  the  neighborhood  of  a  septic 
wound. 

The  appearance  that  the  lung  presents  is  exceedingly  suggestive  of  a  pro- 
cess of  embolism :  if  this-  has  been  very  extensive,  the  smaller  vessels  may  be 
so  distended  as  to  be  visible  to  the  naked  eye,  and  hemorrhage  or  infarction 
imj  occur ;  while  under  the  microscope,  the  lung-stroma  shows  a  regular 
injection,  mapping  out  all  the  capillaries  and  filling  them  with  some  liquid, 
which,  from  its  reaction  with  perosmic  acid  and  its  rapid  disappearance  under 
ether,  can  be  nothing  else  than  fat.  More  often  there  is  only  a  condition  of 
hyperemia  and  oedema,  and  then  there  may  be  found  here  and  there,  with 
tolerable  regularity,  minute  drops  and  short  cylinders.  These  changes  are 
not  limited  to  any  part  of  the  lung,  though  they  occur,  as  might  have  been 
expected,  most  plentifully  in  the  lower  lobes.  Xot  unfrequently  oil-drops 
have  been  found  in  the  clots  in  the  branches  of  the  pulmonary  artery,  in  the 
right  side  of  the  heart,  and  in  the  large  veins  leading  to  it  from  the  seat  of 
injury.  So  that  post-mortem  evidence  alone  renders  certain  the  presumption 
that  the  process  is  really  one  of  embolism. 

1  Miiller,  Wurzburg  med.  Zeit.,  1860. 

8  Zenker,  Beitrag.  z.  norm,  unci  path.  Anat.  d.  Lunge,  1S62. 

8  Wagner,  Archiv  d.  Heilkunde,  1862.  *  Ibid.  1865 

6  Zur  Lehre  v.  d.  Fettembolie.     Dorpat,  1863. 


376  shock. 

The  nature  of  the  accident  or  disease  in  which  this  complication  arises, 
renders  it  still  more  clear :  it  is  always  one  in  which  the  rupture  of  fat-cells 
may  reasonably  be  supposed  to  occur ;  and  the  greater  the  chance  of  this,  the 
more  extensive  the  embolism.  This  is  probably  the  reason — joined  to  the 
fact  that  the  veins  are  torn  and  cannot  close— that  it  has  been  observed  with 
such  frequency  after  fractures ;  so  frequently,  indeed,  that  it  has  been  said  to 
be  a  normal  occurrence.  Thus  it  is  always  proportionate,  in  simple  fractures, 
to  the  amount  of  injury  inflicted  on  the  medulla,  and  to  the  number  and  size 
of  the  bones  that  are  broken ;  bearing  out  thoroughly  the  experiments  of 
Vulpian,1  who  showed  that  in  animals,  while  in  simple  fracture  embolism 
was  sometimes  hard  to  find,  yet,  when  a  foreign  body  Avas  introduced  into 
the  medulla,  there  never  was  any  difficulty  in  tracing  the  fat  through  its 
whole  course ;  while,  if  the  foreign  body  was  a  tent,  the  lungs  were  simply 
gorged.  But  though  most  commonly  met  with  after  simple  fractures,  and 
perhaps  in  them  of  greatest  clinical  interest  as  offering  an  explanation  for 
deaths  that  under  ordinary  conditions  seem  utterly  unintelligible,  fatty 
embolism  is  by  no  means  confined  to  them.  Many  of  Wagner's  instances 
occurred  in  cases  of  compound  fracture,  and  especially  after  secondary  ampu- 
tation, or  were  found  after  acute  periostitis  (when  metastatic  abscesses  were 
nearly  always  present) ;  while  the  lesion  has  been  noticed  after  simple  suppu- 
ration in  the  connective  tissue;  after  crushing  injuries  of  only  the  fleshy  parts 
of  the  body,  especially  if  they  contained  much  adipose  tissue ;  after  rupture  of 
fatty  liver ;  in  chronic  inflammation  connected  with  bone ;  as  the  result  of 
fatty  degeneration  of  thrombi ;  in  icterus  gravis,  and  in  diabetes.  Indeed,  so 
common  is  it,  that  Flournoy,2  examining  all  the  bodies  brought  into  the 
Pathological  Institute  at  Strasbourg,  found  it  in  no  less  than  ten  per  cent. 

Quite  a  number  of  observers  have  seen,  in  compound  fractures,  oil-drops 
flowing  out  with  blood  from  the  medullary  cavity,  and  haATe  afterwards  found 
similar  ones  in  the  veins  leading  from  the  limbs ;  but  till  recently  it  was 
believed  that  this  was  the  only  channel  by  which  the  fat  was  taken  up ;  it 
is,  however,  clear,  from  fresh  experiments,3  that  tatty  embolism  of  the  lungs 
may  follow  within  a  few  hours  if  any  oil  gain  access  to  a  serous  surface,  and 
even,  though  at  a  much  later  date  and  to  a  much  more  limited  extent,  when 
it  is  set  free  in  the  connective-tissue  spaces.  The  delay  and  the  diminution 
may  probably  be  accounted  for  by  the  fat  having  to  pass  through  lymphatic 
glands  on  its  way,  and  probably  becoming  emulsified  in  them. 

It  is  not  easy  in  all  cases  to  account  for  the  force  which  is  necessary  to 
cause  the  oil-drops  to  enter  the  veins ;  sometimes,  perhaps,  the  nature  of  the 
accident  itself  will  give  a  reason  for  it ;  in  other  cases,  it  has  been  suggested 
that  the  liquid  fat  from  the  broken-down  cells  stagnating  in  a  wound,  is  sud- 
denly caught  up  when  the  state  of  syncope  passes  off  and  the  heart  recovers ; 
or  it  may  be,  as  Vulpian's  experiments  suggest,  that  from  the  commencement 
of  inflammation  there  is  a  sudden  increase  of  pressure  and  local  tension. 

In  studying  the  effect  of  fatty  embolism,  it  is  necessary  to  distinguish 
clearly  between  the  results  of  clinical  observation  and  the  data  furnished  by 
experiment ;  for  while  in  the  latter  every  precaution  can  be  taken  to  exclude 
other  influences,  there  can  be  no  question  that,  in  the  former,  other  things 
besides  fat  can  gain  access  to  the  circulation.  The  most  recent  and  careful 
experiments  that  have  been  conducted  for  the  purpose  of  ascertaining  the 
cause,  of  death,  are  detailed  by  Scriba4  in  a  monograph  on  this  subject.  By 
injecting  carefully  purified  oil  into  the  veins,  into  the  medulla  of  bones,  and 

1  D6jerine,  Progrfes  Medical,  1879. 

2  Egli-Sinclair,  Corresp.-Bl.  f.  Schweizorische  Aerzte,  No.  vi.,  1870. 

8  Wiener  Archiv  f.  exper.  Path.,  Bd.  xi.  *  Uutersuchungeii  iil>er  die  Fettembolie. 


FATTY    EMBOLISM.  377 

into  the  peritoneal  cavity  of  rabbits,  Scriba  has  been  able  to  confirm  the  views 
of  Bergmann,1  that  the  symptoms  depend  mainly  on  the  quantity  injected 
and  the  rapidity  with  which  it  is  introduced,  or  the  proximity  of  the  vein 
selected  to  the  heart ;  in  this  way  it  is  possible  to  vary  the  result  from  a 
death  so  instant  as  only  to  bear  comparison  with  the  injection  of  air  into  the 
veins,  to  the  slightest  possible  dyspnoea ;  and  even  this  may  be  wanting, 
though  after  death  the  fat  may  actually  be  found  arrested  in  the  lungs. 
Scriba  finds,  moreover,  that,  if  the  distance  from  the  heart  of  the  point  of 
entrance  of  the  fat  into  the  circulation  be  at  all  great — as  in  the  majority  of 
fractures  taking  place  in  the  human  subject  it  would  be — and  if  the  force 
that  propels  it  into  the  veins  be  slight,  the  quantity  required  to  produce  any 
alarming  symptoms  in  an  animal  is  very  great;  in  no  case  is  Scriba  of  opinion 
that  death  can  be  caused  by  the  injection  of  less  than  three  times  the  amount 
of  blood  present  in  the  femur  of  an  animal. 

Further,  much  light  has  been  thrown  by  experimentation  on  the  ultimate 
destiny  of  the  fat  that  is  carried  into  the  pulmonary  capillaries — a  point  of 
great  clinical  significance ;  for  it  is  not  impossible  that,  in  some  cases,  the 
particles  may  be  carried  off,  and,  by  their  subsequent  impaction  in  other 
organs,  cause  even  more  serious  mischief.  Some  undoubtedly  pass  at  once, 
without  any  detention,  through  the  pulmonary  circulation,  and  either  form 
emboli  elsewhere,  or  are  caught  up  by  the  glomeruli  of  the  kidney  and 
excreted  with  the  urine ;  for,  after  injection  of  fat,  large  masses  have  been 
found  in  the  urine  and  the  vasa  atferentia ;  glomeruli  and  tubules  have  been 
seen  full  of  it,  while  the  same  condition  has  been  detected  after  fractures  in 
man.  Indeed,  from  the  intermittent  appearance  of  oil  in  the  urine,  from  its 
abundance  for  the  first  few  days,  and  then  its  absence  till  the  end  of  the  second 
week,  when  it  may  appear  again  for  a  short  time,  Scriba  concludes  that  in 
man,  after  the  lapse  of  from  six  to  eight  days,  the  emboli  become  detached, 
and  that  they  then  pass  on  either  to  be  excreted  by  the  kidneys,  or  to  be 
caught  by  the  capillaries  in  other  organs — these  in  their  turn  setting  free  the 
particles  they  originally  detained  to  be  carried  into  the  veins,  and  so  cause, 
as  it  were,  secondary  pulmonary  embolism.  It  has  happened,  somewhat 
unfortunately,  that  in  very  many  of  the  recorded  cases  no  observations  were 
made  on  the  presence  of  oil  in  the  capillaries  of  other  organs ;  but  it  has 
been  observed  in  the  liver  (though  not  to  any  large  extent,  possibly  from  the 
action  of  the  hepatic  cells  which  may  take  it  up),  and  on  several  occasions2  in 
the  brain  and  spinal  cord. 

The  symptoms  characteristic  of  fatty  embolism,  when  uncomplicated, 
besides  the  presence  of  oil  in  the  urine  at  irregular  intervals,  and  the  dys- 
pnoea, which  of  course  varies  with  the  number  of  capillaries  obstructed,  are 
a  fall  rather  than  a  rise  of  temperature,  slight  haemoptysis  with  irregular 
action  of  the  heart,  pallor  and  lividity  of  the  skin,  shallow  respiration  grad- 
ually passing  into  Cheyne-Stokes  breathing  as  the  case  becomes  worse,  and 
loss  of  reflex  excitability  with,  at  times,  spasms  of  various  kinds,  or  paral yses. 
But  it  is  very  seldom  that  the  symptoms  met  with  after  accidents  or  operations 
resemble  these ;  much  more  often  there  is  observed  a  condition  of  which  an 
excellent  example  is  given  in  a  case  related  by  Southam  :3  the  operation 
(primary  amputation  of  both  lower  extremities)  was  borne  well ;  a  comfort- 
able night  was  passed  ;  and  the  general  condition  was  regarded  as  satisfactory, 
though  the  temperature  had  risen  from  101°. 2  F.  the  previous  evening,  to 
103°  F.  in  the  morning.  Suddenly,  in  the  afternoon,  the  patient  became 
restless  and  excited,  his  face  wore  a  dusky  look,  his  pulse  and  respiration 

1  Berliner  klin.  Wochenschrift,  Aug.  18,  1873. 

2  Czerny,  Berlin,  klin.  Wochenschrift,  Nov.  1875.  Lancet,  July  10,  1880. 


378  shock. 

became  more  rapid  and  feeble,  and,  though  there  was  no  rigor  or  marked 
dyspnoea,  by  the  evening  the  patient  was  delirious,  sinking  fast  with  a  tem- 
perature still  rising,  and  it  was  evident  that  the  wounds  were  no  longer 
aseptic.  At  the  autopsy,  though  no  change  of  importance  was  visible  to  the 
naked  eye,  yet  microscopic  examination  showed  the  capillaries  and  arterioles 
of  the  lungs  to  be  simply  tilled  with  oil  globules.  In  nearly  all  the  instances 
that  have  recently  been  reported  at  length,  the  symptoms  resembled  these. 
Boettseher1  gives  the  particulars  of  a  case  of  gunshot  wound  of  the  knee- 
joint,  fatal  on  the  third  day  from  sudden  collapse,  and  states  that  the  lungs 
were  intensely  hypersemic  and  full  of  fluid  fat.  Czemy's2  case  was  somewhat 
different,  in  that  it  was  one  of  simple  fracture  of  the  femur ;  but,  like  the 
rest,  there  was  a  gradual  rise  of  temperature  with  sudden  dyspnoea  and 
cyanosis  on  the  morning  of  the  second  day ;  post-mortem  evidence  of  fatty 
embolism  was  abundant,  not  only  in  the  lungs  but  in  the  brain,  liver,  and 
kidneys,  all  of  which  were  studded  with  small  ecchymoses.  Dejerine3  gives 
the  particulars  of  a  case  in  which  a  leg  was  severely  crushed,  and  which 
proved  fatal  within  seven  hours;  but,  though  the  lungs  were  full  of  oil,  there 
had  been  no  marked  dyspnoea.  In  short,  it  seems  impossible  to  reconcile  the 
clinical  data  with  the  knowledge  derived  from  experimentation ;  in  the  latter 
the  conditions  are  known  ;  in  the  former  there  must  be  something  else  to 
cause  the  rise  of  temperature  and  other  symptoms. 

It  is  not  meant  that  fatty  embolism  does  not  take  place  after  accidents,  or  that 
when  it  is  extensive  it  is  not  dangerous  from  the  effect  which  it  must  produce 
on  the  respiration  and  circulation,  and  perhaps  from  another  cause  recently 
pointed  out,  the  solution  of  blood  corpuscles  by  its  agency;  but  that  it  is 
scarcely  possible  to  conceive  of  its  being  so  extreme  as  to  obstruct  the  circu- 
lation through  the  lungs  and  so  cause  death  ;  or  so  extensive  as  to  bring  on 
the  same  result  by  occluding  small  vessels  in  the  brain  or  spinal  cord — the 
conclusion  at  which  Scriba  arrived  from  the  artificial  production  of  uncom- 
plicated fatty  embolism  in  animals.  It  seems,  on  the  whole,  much  more  rea- 
sonable that  it  should  be  regarded  either  as  an  addition  to  that  form  of  acute 
blood-poisoning  known  as  "  collapse  with  cyanosis,"  which  is  particularly 
likely  to  set  in  on  the  second  or  third  day  after  an  injury,  and  which  is  much 
more  consonant  with  the  symptoms  in  the  majority  of  the  eases;  or,  where  the 
change  has  set  in  earlier,  as  a  complication  which,  added  to  the  already  exist- 
ing nervous  prostration  and  the  loss  of  blood,  is  sufficient  to  turn  the  scale. 
But  a  much  wider  series  of  observations  is  required  before  this  question  can 
be  regarded  as  in  any  way  definitely  settled.  Of  its  importance  there  can 
be  no  doubt;  already  upwards  of  one  hundred  and  forty  instances  have  been 
recorded  in  Germany  alone,  and  the  fatty  embolism  was,  according  to  Egli- 
Sinclair,  the  cause  of  death  in  no  less  than  thirteen  per  cent,  of  these. 

Still  less  is  known  with  regard  to  the  significance  of  fatty  embolism  in 
diabetes.  The  occasional  lactescent  state  of  the  blood  serum  in  this  disease, 
has  long  been  known;  and  recently4  it  has  been  shown  to  be  due  to  the  pres- 
ence of  fine  molecules  of  oil  ;  and  fatty  embolism  of  the  lungs  and  kidneys, 
exactly  similar  to  that  appearing  after  fractures,  has  been  found  in  a  patient 
dying  in  thai  condition  of  coma  which  is  not  uncommon  towards  the  end  of 
this  affection.  But  the  relation  existing  between  these  conditions  is  quite 
uncertain  ;  death  in  a  state  of  coma,  with  an  enormous  increase  in  the  amount 
of  molecular  oil  in  the  Mood,  is  at  least  quite  consistent5  with  the  complete 
absence  of  fatty  embolism. 

1   Dorp.it.  mod.  Zeitschrift,  1877,  S.  326. 

«  Berliner  klin.  Wochenschrift,  Nov.  1878.  8  Progrea  Me'dical,  1879. 

4  Edinburgh  Med.  Journal,  1879.  6  Gamgee,  Physiological  Chemistry,  p.  171. 


TRAUMATIC  DELIRIUM  AND  DELIRIUM  TREMENS. 

BY 

WILLIAM  HUNT,  M.D., 

SENIOR  SURGEON   TO  THE  PENNSYLVANIA  HOSPITAL,   PHILADELPHIA. 


Traumatic  Delirium. 

The  word  Delirium  has  rather  a  curious  derivation  from  de  (from),  and  lira 
(a  ridge  between  two  furrows).  The  Latin  verb  deliro  is  defined  as  "  to  make  a 
balk  in  plowing."  A  free  translation,  therefore,  would  be  to  deviate  or  wander 
from  a  prescribed  line.  Hence  the  word  "wandering,"  that  is  often  used  to 
express  the  presence  of  delirium  in  disease.  Those  who  coined  the  word  did 
better  than  they  knew,  if  our  present  knowledge  of  the  brain  and  its  func- 
tions is  taken  into  account.  As  knowledge  of  the  localization  of  nerve 
centres  and  their  conducting  fibres  becomes  more  and  more  developed,  we  can 
readily  understand  how  the  furrows  and  ridges  and  folds  of  nerve  matter  may 
be  disturbed  by  a  balk  of  the  driver  (external  impression),  or  by  a  stump  in 
the  furrow  (internal  disease).  A  temporary  derangement  of  the  intellectual 
and  perceptive  faculties,  manifested  through  the  speech  and  actions  of  the 
patient,  is  the  necessary  characteristic  of  delirium.  The  wandering  need  not 
be  by  speech  alone,  for  a  deaf  mute,  or  an  aphasiac,  may  become  as  delirious 
as  any  one  else,  and  delirium  is  uncmestionably  experienced  by,  and  may  be 
produced  in,  animals. 

Continuous  or  chronic  delirium  necessarily  becomes  insanity,  and  techni- 
cally should  be  considered  under  that  head.  The  case  may  be  a  fatal  one,  as 
far  as  the  individual  patient  is  concerned,  and  the  delirium,  in  a  more  or  less 
acute  form,  may  be  continuous  until  his  death  ;  but  should  he  survive,  and 
the  delirium  persist  indefinitely,  his  place  would  be  among  the  insane.  This 
temporary  character  of  true  delirium  varies  in  its  expression  to  a  remarkable 
degree.  Sometimes  it  shows  itself  as  a  mere  passing  fancy,  and  is  difficult  to 
detect;  again,  the  patient  may  be  perfectty  himself  as  long  as  his  attention  is 
directed  by  another,  or  to  some  special  object,  but,  these  conditions  ceasing,  he 
relapses  into  his  absurd  utterances  or  actions.  Then  moments,  and  sometimes 
extended  periods,  of  normal  consciousness  follow,  during  which  he  will  be 
more  or  less  aware  of  what  has  passed,  and  will  own  to  himself,  or  to  his 
attendants,  that  he  has  been  "making  a  fool  of  himself,"  and  will  declare  that 
he  will  not  do  it  again.  Soon,  however,  there  is  a  recurrence  of  the  wander- 
ing and  the  nonsense,  and,  should  the  disease  get  the  upper  hand,  these  may 
continue  in  a  more  aggravated  form  and  without  intermission  until  death. 
The  actions  of  the  patient  also  vary  very  much,  and  range  from  trivial  devia- 
tions from  the  normal  standard,  such  as  it  would  require  an  expert  to  detect, 
to  the  most  violent  efforts,  threatening  injury  to  himself  and  to  his  caretakers. 

(379) 


380  TRAUMATIC    DELIRIUM   AND   DELIRIUM    TREMENS. 

Anatomy  of  Delirium. — Delirium  is  eminently  one  of  those  conditions  to 
which  the  convenient  word  "functional"  is  applicable,  when  we  seek  for  an 
explanation  of  its  phenomena.  It  manifests  itself,  as  far  as  we  know,  through 
impressions  made  upon  the  cortical  gray  substance  of  the  brain.  The  cells 
and  fibres  of  this  substance,  therefore,  must  be  in  a  receptive  condition,  and 
need  not  of  themselves  deviate  from  the  normal  state.  In  fact,  a  perfectly 
healthy  cortical  matter,  if  the  received  physiological  views  of  its  purposes 
are  correct,  is  more  consistent  with  the  occurrence  of  the  severest  forms  of 
delirium  than  one  which  is  otherwise.  Its  functions  are  disturbed  by  its 
environment,  in  the  form  of  meningeal  inflammations,  or  by  slight  irritative 
exudations  or  hemorrhages  pressing  upon  it.  Great  pressure  would  sup- 
press its  workings  altogether.  Again,  it  may  be  harassed  from  without  by 
alterations  in  the  quantity  and  quality  of  the  blood  which  is  sent  to  it,  and 
which  may  be  charged  with  the  products  of  disease,  or  overloaded  with  poisons. 
Then  the  special  senses,  being  set  agog  from  the  same  causes,  bring  wrong 
impressions  to  it,  which  it  must  needs  take  up  and  discharge,  in  the  form  of 
wrong  thought,  wrong  talk,  and  wrong  action.  The  necessity  of  this  recep- 
tive faculty  of  the  gray  matter  for  the  production  of  delirium,  is  further 
proved  by  the  meagre  mention  of  delirium  as  a  symptom,  when  the  brain 
itself,  excepting  the  cortex,  has  been  made  the  subject  of  experiment  or  clini- 
cal observation.1 

Thus  in  lesions  of  the  Pons,  a  tendency  to  cry  more  than  to  laugh  is  noted. 
There  is  emotional  weakness,  which  might  be  taken  for  hysteria,  but  no  men- 
tion of  delirium.  The  Crura  being  disturbed,  paralysis  of  the  third  nerve 
follows,  and  the  diplopia  and  confusion  of  vision  thus  caused,  together  with 
a  certain  confusion  of  speech,  probably  owing  to  some  facial  paralysis,  may 
readily  give  rise  to  the  idea  that  delirium  is  present,  when  really  the  intel- 
lectual faculties  are  undisturbed.  After  the  first  effects  of  a  lesion  of  the 
corpus  striatum  are  over,  the  absence  of  mental  disturbance  is  particularly 
noted.  There  may  be  slight  thickness  of  speech  and  also  emotional  phe- 
nomena, but  no  delirium.  Injury  of  the  thalamus  is  attended  by  less  distinct 
signs  than  injury  of  the  striate  bodies;  but  delirium  is  not  noted  as  one  of  its 
symptoms.  Injuries  of  the  white  substance  of  the  hemispheres  are  not  pro- 
ductive of  delirium,  nor  do  I  find  it  mentioned  as  belonging  to  lesions  pur- 
posely inflicted  upon  the  cerebellum.  The  posterior  and  inferior  parts  of  the 
frontal  lobes,  being  injured,  give  rise  to  typical  aphasia,  and  a  careless  observer 
might  construe  its  manifestations  as  those  of  delirium. 

Certain  portions  of  the  cortical  gray  matter,  then,  of  the  surfaces  of  the 
hemispheres  and  their  convolutions,  being  subjected  to  irritative  influences, 
are  the  seats  of  delirium.  These  remarks  are  confirmed  by  clinical  observa- 
tion. It  is  to  be  understood  that  delirium  may  coexist  with  affections  or 
injuries  of  some  of  the  other  regions  above  mentioned,  but  when  it  does 
so,  there  is  every  reason  to  believe  that,  in  most  cases,  it  is  due  to  the  neigh- 
boring meninges  being  more  or  less  involved.  Dr.  Morris  Longstreth  informs 
me  that  he  has  analyzed  the  histories  of  more  than  three  hundred  brain 
tumors,  and  that  delirium  is  rarely  mentioned  as  one  of  their  features,  and 
that,  when  it  is,  it  may  be  readily  accounted  for  by  implication  of  the  mem- 
branes, these  in  their  turn  affecting  the  cortical  matter.  When  formerly 
Demonstrator  of  Anatomy  in  the  University  of  Pennsylvania,  I  have  no 
dpubl  that  I  showed  many  splendid  brains,  the  original  possessors  of  which 
had  been  "mad  as  March  hares."  The  supply  of  subjects  was  large,  and  many 
of  them  must  have  come  from  the  "  Insane  Wards"  of  the  Almshouse.  J  can 
call  to  mind  glued  membranes,  masses  of  old  lymph,  pearly  arachnoids,  and 

1  Carpenter,  Bastian,  Ferrier,  Charcot. 


CAUSES   OF   TRAUMATIC    DELIRIUM.  381 

ossific  deposits  ;  but,  these  being  removed,  I  sliced  and  dissected  and  lectured 
upon  as  pretty  brains  as  an  enthusiast  in  anatomy  would  wish  to  see.  I 
remember  one  in  which  the  old  lymph  mass  was  so  extensive,  that  it  actually 
formed  a  secondary  membrane  covering  both  hemispheres;  and  yet  beneath 
was  a  beautiful  brain.  What  havoc  must  have  been  caused  to  the  intellectual 
and  perceptive  demonstrations  of  the  cells  of  the  cortex! 

My  own  clinical  observations  incline  me  to  agree  with  those  (Hughlings 
Jackson  and  others)  who  think  that  the  posterior  lobes  of  the  hemispheres 
have  more  to  do  with  ordinary  intellectual  processes  than  the  anterior.  A 
very  large  number  of  cases  of  injury  of  the  cortex  have  come  under  my 
care,  and  I  have  frequently  noted  and  spoken  of  the  almost  absolute  indiffer- 
ence in  this  respect  with  which  enormous  injuries  to  the  frontal  lobes  are 
borne.  I  have  seen  masses  of  brain  come  away  from  these,  and  also  from  the 
middle  lobes,  without  any  apparent  intellectual  disturbance.  If  the  case  were 
fatal,  delirium  would  come  on  towards  the  end,  there  having  been  ample  time 
for  the  irritation  to  spread  ;  but,  recovery  following  the  injury,  I  have  known 
the  patient  to  convalesce  without  a  single  incoherent  manifestation.  In  fact, 
I  am  disposed  to  think  that  in  such  cases  recovery  is  the  rule  rather  than  the 
exception.  I  am  sure,  however,  that  this  is  not  so  when  the  posterior  lobes 
are  the  seats  of  cortical  injury.  Delirium  then  often  sets  in  at  once,  and  may 
cease  as  pressure  from  hemorrhage  or  effusion  increases,  but,  this  being 
removed  by  operation  or  absorption,  is  apt  to  return,  and  will  abate  or 
increase  in  accordance  with  the  progress  to  recovery  or  death.  These  inju- 
ries, therefore,  are  much  more  dangerous  to  life  and.  to  mind  than  the  others. 
Inflammatory  products,  effusions,  hyperemia  and  anosmia, alterations  in  quality 
as  well  as  quantity  of  blood  supply,  are  then  more  potent  causes  of  the  symp- 
tom delirium,  than  pathological  changes  in  the  nerve  substance  proper. 

Causes  of  Traumatic  Delirium.— The  foregoing  remarks  have  necessarily 
included  the  consideration  of  those  forms  of  traumatic  delirium  which  accom- 
pany immediate  injuries  to  the  brain  substance  and  its  membranes.  By  far 
the  greater  number  of  cases  of  delirium  coming  under  the  notice  of  the  sur- 
geon, as  well  as  of  the  physician,  arise  from  causes  external  to  the  brain,  and 
consequently  have  their  origin  in  anything  which  may  affect  the  quality  or 
quantity  of  the  blood.  Of  these,  those  affecting  the  quality  are  the  most 
numerous,  and  hence  immediate  delirium  is  not  nearly  so  common  in  exter- 
nal, surgical  cases,  as  the  delirium  which  ensues  after  time  enough  has  elapsed 
to  bring  about  various  septic  changes. 

One  cause  of  immediate  delirium  is  great  and  sudden  hemorrhage.  This 
variety  generally  finds  expression  in  a  mild  form  of  rambling,  that  is  more 
apt  to  be  indicative  of  pleasant  sensations  than  otherwise.  Should  fainting 
occur,  sufficient  to  check  the  bleeding,  and  if,  in  the  mean  time,  surgical 
appliances  be  successfully  used  to  prevent  its  recurrence,  the  patient  reacts, 
sometimes  very  rapidly,  and  will  often  speak  regretfully  of  the  glories  through 
which  he  has  passed.  If  the  case  prove  to  be  a  fatal  one,  a  distressing  rest- 
lessness sets  in,  and  this  with  the  delirium  continues  until  death. 

There  is  a  rather  rare  form  of  immediate  traumatic  delirium,  which  neverthe- 
less must  be  more  or  less  familiar  to  every  surgeon  of  a  great  accident  hospital, 
or  to  those  who  are  in  any  position,  as  upon  the  battle  field,  where  they  become 
familiar  with  severe  and  sudden  casualties.  Delirium  might  appear  to  some 
to  be  a  misnomer,  for  the  characteristic  is  that  every  word  and  idea  are  per- 
fectly coherent.  There  is  great  exaltation  of  mind,  but  an  utter  want  of  ap- 
preciation of  the  bodily  injuries.  Commonly  the  spine  has  been  involved  in 
the  crush,  and  the  line  of  communication  with  the  brain  has  been  cut  off,  but 
this  is  not  necessarily  the  case.     There  is  no  collapse  at  first:  the  skin  has  its 


382  TRAUMATIC   DELIRIUM   AND   DELIRIUM    TREMENS. 

normal  temperature,  the  pulse  is  full  and  rather  frequent,  the  face  may  be 
more  flushed  than  natural,  the  eyes  bright,  and  the  expression  good. 

The  surgeon  enters  a  ward  some  morning,  after  a  terrible  accident  has  occurred,  and 
finds  that  a  victim  of  this  kind  has  just  been  brought  in  and  laid  upon  a  bed.  He  is  at 
once  recognized  by  the  patient  as  one  in  authority.  "  How  are  you,  doctor,"  he  says, 
in  a  high  voice;  "what  have  they  brought  me  here  for?  I'm  not  hurt!  No,  sir!  Look 
at  that,"  and  out  goes  an  arm  with  the  force  of  a  prize  fighter  delivering  a  crusher. 
"  Look  here,"  and  he  tries  to  lift  a  leg,  which  his  sensorium  falsely  tells  him  he  has  done, 
although  his  expression  may  indicate  a  vague  and  passing  doubt.  "  Why  there's  my 
wife  !  Molly,  what  are  you  doing  here  ?  don't  cry  ;  what  are  you  crying  for  ?  I'm  not 
hurt;  go  home  to  the  children  and  tell  them  I'll  be  there  to  supper  and  at  the  mills  to- 
morrow. "Won't  I,  doctor?  Go  home!"  Soon  this  great  tension  gives  way,  collapse 
comes  on,  and  by  night  the  patient  is  in  another  home  than  that  in  which  he  promised 
to  be.     I  have  never  known  such  a  case  to  recover. 

With  all  its  coherence,  with  every  intellectual  and  perceptive  process  cor- 
rect as  far  as  external  matters  are  concerned,  every  word  and  thought  as  to 
other  persons  and  objects  right,  everything  as  to  himself  wrong,  how  are  we 
to  classify  this  state,  except  as  one  of  delirium  ?  Important  questions  might 
arise  as  to  the  testamentary  capacity  of  such  persons  ;  from  what  I  have  seen 
and  described,  there  is  nothing  in  their  condition  inconsistent  with  full 
ability  to  direct  the  management  of  their  estates  and  effects. 

Shock  after  injury  is  a  condition  so  intimately  involving  the  nervous  sys- 
tem, both  cerebro-spinal  and  organic,  that  delirium  might  be  reasonably 
looked  for  as  a  common  accompaniment  of  it.  This  symptom,  however,  is 
rarely  present  during  the  stage  to  which  the  term  shock  is  applicable.  The 
intellectual  and  perceptive  faculties  simply  experience  the  profound  depres- 
sion which  is  present  everywhere.  The  nearly  pulseless,  pale,  cold  body  ;  the 
dull  eyes  and  drooping  lids  ;  the  slow  and  feeble  respiration,  and  the  shrunken 
and  clammy  skin,  are  all  expressive  of  that  general  condition,  in  which  the 
brain  itself  takes  part.  In  fact,  shock  without  reaction  means  death,  and 
many  die  in  this  condition.  During  its  continuance,  there  may  be  some  slight 
mutterings,  which  increase  if  death  is  to  come;  but  upon  being  spoken  to,  it 
will  be  found  that  the  patient's  intelligence  is  retained,  and  only  sluggish. 
He  wishes  to  be  let  alone,  is  indifferent  as  to  what  it  all  means,  becomes  colder 
and  weaker,  and  dies  ;  or  warms  up,  it  may  be  sleeps  for  a  short  time,  and 
lives.  It  is  in  this  latter  event,  when  reaction  is  taking  place,  that  delirium 
frequently  occurs.  It  is  apt  to  be  wild,  especially  in  children.  Its  degree  is 
in  accordance  with  the  rapidity  of  return  of  the  general  functions.  The  re- 
bound oversteps  tiie  mark,  and  disturbance  of  the  cortex  is  one  of  the  results. 
E'ortunately  this  kind  of  delirium  does  not  often  last  long.  As  the  skin,  kid- 
neys, ;n  id  other  organs  resume  their  normal  actions,  it  subsides.  Delirium 
may  recur  in  the  future  progress  of  the  case,  but  will  have  other  causes  for  its 
production  than  what  happened  at  the  start. 

Embolism  of  the  cerebral  vessels,  from  the  suddenness  with  which  it  some- 
times takes  place,  one  would  think  would  he  a  cause  of  immediate  delirium. 
1  do  not,  however,  find  tins  mentioned  as  a  prominent  symptom,  or  even  as 
an  ordinary  one,  in  cases  where  the  lesion  is  suspected.  It  may  be  that  the 
limited  area  of  cortex  which  is  supplied  by  the  special  vessel  or  vessels  in- 
volved, is  nourished  sufficiently  from  collateral  sources  to  maintain  its  integ- 
rity, or  that,  if  the  blood  is  entirely  cut  off,  local  death  of  the  delicate  cells 
and  fibres  takes  place  so  rapidly  that  their  receptive  and  demonstrative  pro- 
perties are  lost  at  once.  Thrombosis,  from  the  comparative  slowness  with 
which  it  mostly  occurs,  would  be  more  likely  to  he  accompanied  by  delirium ; 
hut  as  the  vessels  of  the  brain  involved  in  this  process  are  generally  large  and 


CAUSES    OF    TRAUMATIC    DELIRIUM.  383 

basal  ones,  their  influence  upon  the  cortex  is  remote,  so  that  the  symptom  is 
not  one  of  special  note. 

I  recently  had  the  rare  opportunity  of  observing  the  invasion  of  an  attack  of  apoplexy 
in  which  the  lesion,  I  think,  must  have  been  in  the  pons,  although  no  autopsy  was  allowed 
to  confirm  the  opinion.  When  I  first  saw  the  patient,  she  was  entirely  sensible,  but  in  a 
high  state  of  emotional  excitement.  She  complained  much  of  lateral  and  posterior 
headache.  There  was  no  delirium  :  answers  to  questions  were  promptly  and  properly 
given — but  there  was  great  restlessness  in  addition  to  the  excitement;  paralysis  was  not 
then  present,  for  various  acts  were  performed  as  requested.  Knowing  something  of  the 
patient,  I  was  inclined  to  regard  the  attack  as  hysterical,  and  to  prescribe  and  leave 
the  house.  Fortunately  I  remained,  for  soon  quiet  came  on,  the  countenance  became 
suffused  with  redness,  stertorous  respiration  began  and  grew  worse,  and  death  took  place 
in  a  few  hours.  Probably  a  basal  thrombus  had  been  slowly  forming,  which  was  finally 
followed  by  rupture  ;  and  it  may  be  that  some  peculiarities,  which  we  are  apt  to  call 
hysterical,  had,  in  this  case,  their  origin  in  a  pathological  condition  which  was  not  a  re- 
cent one. 

Immediate  delirium  may  also  be  brought  on  by  so-called  subjective  sensations 
arising  from  irritations  or  injuries  of  the  nerves  of  special  sense.  The  particular 
parts  of  the  cortex  (supposed  by  some  to  be  chiefly  in  the  posterior  lobes  of  the 
hemispheres)  which  have  to  take  up  impressions  from  these  nerves  and  discharge 
them  as  perceptions,  know  nothing  else  than  to  develop  these  perceptions  as 
objective  truths  to  the  intellect.  Should  these  apparent  truths  assume  distorted, 
frightful,  or  absurd  forms,  it  is  easy  to  understand  how  the  confusion  created 
would  upset  the  centres  of  congruity  and  produce  delirium.  I  have  already 
spoken  of  the  fact  that  some  authorities  are  disposed  to  give  the  cortex  of 
the  posterior  lobes  of  the  hemispheres  the  preference  over  the  anterior  ones, 
as  seats  of  intellectual  processes.  May  it  not  be  that  the  more  intimate  rela- 
tions of  the  former  with  the  phenomena  of  perception,  and  the  close  connec- 
tion of  these  phenomena  with  the  ordinary  manifestations  of  intellect,  bring 
their  operations  more  readily  under  observation  ;  and  that  deeper  or  abstract 
ideation  has  its  nerve  centres  in  the  anterior  lobes,  these  requiring  for  their 
accommodation  those  cranial  forms  which  s;ive  to  higher  man  "  the  front  of 
Jove  himself?"  Comparative  anatomy  and  the  doctrine  of  evolution  both 
appear  to  sustain  this  view.  As  to  delirium,  the  clinical  facts  which  I  have 
related  about  injuries  to  the  cortex  of  the  frontal  and  posterior  lobes  of  the 
hemispheres,  also  support  it.  Delirium  does  not  deal  with  the  abstract,  but  is 
developed  in  its  highest  degree  by  disordered  perceptions  sending  false  im- 
pressions through  their  transmitters,  which  in  turn  disorder  the  receivers. 
Whatever  the  middle  lobes  may  have  to  do  with  ideation,  the  fact  of  their 
beiug  the  seat  of  centres  through  which  the  will  produces  motor  acts,  seems 
to  be  well  established.  I  have  one  important  clinical  observation  to  sustain 
this  view. 

In  Ferrier  on  "  The  Functions  of  the  Brain,"1  there  is  a  drawing  of  the  surfaces  of 
the  hemispheres  to  illustrate  the  effects  of  local  electrization.  One  of  the  parts  mentioned 
occupies  the  adjacent  margins  of  the  ascending  frontal  and  ascending  parietal  convolu- 
tions, and  this  statement  is  made  in  regard  to  a  certain  part  when  it  was  the  subject  of 
experiment,  "  Retraction  with  adduction  of  the  opposite  arm,  the  palm  being  directed 
backwards."  Now  there  was  a  sailor  under  my  care,  in  1879,  whose  case  I  have  fully 
reported.2  While  at  sea,  he  had  inflicted  very  serious  injuries  upon  the  middle  lobes  of  his 
brain,  by  fracturing  his  skull  with  repeated  blows  of  an  axe  whilst  he  was,  there  is  every 
reason  to  believe,  in  the  delirium  of  heat  fever  and  exhaustion.  The  delirium  actually 
disappeared  after  he  picked  the  pieces  of  bone  away.     The  patient  landed  in  New  York 

'  London,  1876,  p.  142. 

8  Medical  News  and  Library,  Philadelphia,  July,  1879. 


384  TRAUMATIC   DELIRIUM   AND   DELIRIUM    TREMENS. 

four  or  five  days  afterwards,  came  on  to  Philadelphia,  and  walked  to  the  hospital.  He 
was  perfectly  conscious  and  very  intelligent.  Soon  there  was  paralysis  of  the  left  arm, 
with  retraction  (position  of  palm  not  noted),  and  then  paralysis  of  the  leg  of  the  same 
side  followed.  On  dressing  the  wound,  two  pieces  of  hone  respectively  a  quarter  by  half 
an  inch  and  three-quarters  by  three-eighths  of  an  inch  in  size,  were  found  under  the 
anterior  right  margin  of  the  sound  bone,  and  -precisely,  it  is  lair  to  say,  in  the  ]>osition 
which  Dr.  Ferrier  pictures.  Upon  removing  these  pieces,  the  paralysis  at  once  disap- 
peared from  the  arm,  and  by  the  next  day  it  was  gone  from  the  leg.  There  was  no 
active  delirium  at  any  time  after  the  patient's  admission  to  the  hospital.  I  recall  the 
fact  that  I  ordered  him  to  the  basement  of  the  building,  fearing  that  he  would  throw 
himself  from  the  window  should  delirium  come  on.  After  having  been  there  one  night, 
he  protested  against  it ;  said  he  was  perfectly  himself,  and  begged  to  be  removed  to  his 
room  up  stairs.  His  request  was  complied  with,  and  he  remained  quiet  and  rational 
until  a  day  or  two  before  death,  when  coma  came  on  without  antecedent  delirium. 
As  the  brain  became  more  and  more  disorganized,  the  paralysis  returned  and  became 
general.  He  lived  twenty-four  days  after  the  removal  of  the  pieces  of  bone,  and 
forty  days  from  the  time  of  the  original  injury.  The  lesion  here  was  in  the  middle 
lobes;  a  very  extensive  abscess  had  formed,  and  the  softening  had  extended  as  deeply 
as  the  corpus  callosum. 

Immediate  traumatic  delirium,  it  might  be  reasonably  inferred,  would  be 
among  the  symptoms  following  the  bites  of  poisonous  serpents.  Besides  the 
specific  virus,  there  are  the  elements  of  horror  and  fright  to  aid  in  its  pro- 
duction. Experience,  however,  does  not  at  all  confirm  such  an  inference. 
Deaths  from  snake-bite  are  preceded  by  stupor  and  coma,but  delirium  rarely 
exists,  even  for  a  short  time.  This  is  true  not  only  as  to  fatal  cases,  but  also 
as  to  those  which  end  in  recovery.  A  very  large  number  of  cases  of  snake-bite 
are  reported  by  Sir  J.  Fayrer,  in  his  splendid  work,  "The  Thanatophidia  of 
India."  I  have  looked  carefully  over  these  reports,  and  have  not  once  detected 
the  word  delirium;  yet  there  was  everything  to  suggest  it.  The  words  fright, 
depression,  lethargy,  stupor,  coma,  and  unconsciousness,  are  continually  used 
in  the  descriptions.  But,  until  these  last  phenomena  occurred,  the  intelli- 
gence of  the  victims  appears  to  have  been  remarkably  good.  In  some  cases 
it  took  a  few  minutes  to  kill,  and  in  others  hours ;  in  one  doubtful  case,  nine 
days ;  and  yet  no  delirium  is  mentioned.  As  Sir  J.  Fayrer  says,  the  poison 
"kills  by  annihilating  the  source  of  nerve  force."  He  mentions  the  fact  that 
pyaemia  may  arise,  when  the  patient  lives  long  enough  to  have  a  suppurating 
wound  from  the  bite.  Then  of  course  delirium  might  exist  as  a  consequence 
of  this  affection,  but  I  do  not  think  that  any  case  in  which  it  occurred  is 
given.  Fright  is  sometimes  so  excessive  as  to  bring  the  patient  near  unto 
death,  and  we  are  told  to  encourage  and  cheer  him  as  a  part  of  the  treatment, 
This  of  course  would  be  useless  if  he  were  in  a  state  of  delirium.  The  same 
may  be  said  of  cases  of  rattlesnake  poisoning.  Dr.  R.  M.  McClellan,  who 
lived  tor  some  years  in  a  part  of  Georgia  where  rattlesnakes  are  very  common, 
tells  me  that  he  has  seen  from  ten  to  fifteen  cases  of  persons  bitten  by  them. 
The  nervous  symptoms,  as  from  the  bites  of  the  Indian  serpents,  were  those 
of  stupor  and  coma,  but  there  was  no  delirium.  Even  enormous  amounts  of 
whiskey,  used  as  a  remedy,  would  not  occasion  the  excitement  of  drunken- 
ness. Dr.  E.  B.  Shapleigh  treated  a  case  of  rattlesnake  bite  which  occurred 
in  this  city  (Philadelphia).  The  patient  was  rational  throughout  his  brief 
illness,  ami  made  his  will  twenty  minutes  before  his  death.  Dr.  Weir  Mit- 
chell, who  made  some  years  since  an  exhaustive  study  of  the  effects  of 
rattlesnake  bites,  also  confirms  these  views.  These  observations  are  of  prac- 
tical value.  II'  intense  hysterica]  excitement,  approximating  delirium,  or 
even  delirium  itself,  should  follow  in  the  case  of  a,  person  supposed  to  have 
been  bitten  by  a  poisonous  snake,  there  would  be  almost  a  certainty  that  the 


CAUSES    OF   TRAUMATIC    DELIRIUM.  385 

accident  had  not  happened.  Sir  J.  Fayrer,  indeed,  relates  one  case  in  which 
the  patient  was  almost  frightened  to  death,  but  recovered  rapidly  on  its  being 
found  that  the  snake  which  had  bitten  him  was  not  poisonous. 

The  bites  and  stings  of  certain  venomous  spiders  and  insects,  not  being  so 
overpowering  as  those  of  serpents,  might  possibly  give  rise  to  delirium.  A 
sort  of  delirium  is  described  as  following  the  bite  of  the  tarantula;  but  there 
is  reason  to  believe  that  much,  if  not  all,  that  is  related  about  this  creature 
is  fabulous.  Death  sometimes  follows  the  stings  of  bees,  wasps,  or  hornets. 
In  such  cases,  there  is  nothing  more  likely  than  that  delirium  should  arise, 
both  from  the  pain  and  from  the  extent  of  surface  affected.  There  is  a  con- 
dition produced  analogous  to  erysipelas,  and,  if  extensive  enough,  high  febrile 
excitement  with  consequent  delirium  might  occur. 

The  furious  stage  in  hydrophobia  is  one  that  might  be  classed  with  delirium, 
from  its  temporary  character,  and  yet  during  the  paroxysm,  when  phrensy 
appears  to  possess  the  brain,  there  is  a  mental  clearness  inconsistent  with  the 
idea  of  delirium.  The  derangement  expresses  itself  in  acts  rather  than  words ; 
incongruous  thought  is  not  a  part  of  it,  for  the  patient  seems  fully  aware  of 
what" is  going  on,  though  he  has  no  power  of  will  to  control  his  deeds.  A 
low  and  true  delirium,  indicative  of  exhaustion,  may  come  on  as  death  ap- 
proaches. 

In  tetanus,  there  is  no  delirium.  Even  during  the  most  violent  spasms,  the 
mind  remains  perfectly  clear.  The  excito-motor  and  sensitive  tracts  of  the 
cord,  both  direct  and  reflex,  are  strained  to  their  utmost,  whilst  the  cortex, 
unhappily  maintaining  its  integrity,  does  its  full  part  here  in  the  development 
of  su tiering. 

In  chorea,  there  is  no  delirium  even  when  the  subjects  of  it  have  received 
most  severe  injuries,  or  have  undergone  operations.  I  have  reported  a  case1 
of  fracture  in  such  a  patient,  who  actually  died  from  the  exhaustion  of  his 
incessant  movements  and  the  consequent  irritation  of  the  broken  fragments 
of  bone.  His  brain  was  a  perfect  one.  Yvliat  morbid  force  kept  up  the 
involuntary  motor  excitement,  I  do  not  know;  but  it  was  certainly  not 
expended  on  the  cells  of  the  cortex. 

Sometimes  traumatic  delirium  comes  on  shortly  after  capital  surgical  opera- 
tions have  been  performed  on  account  of  severe  injuries.  This  is  much  more 
apt  to  be  the  case  with  children  than  with  adults,  and  it  is  also  more  likely  to 
follow  operations  for  recent,  than  those  for  old,  injuries,  or  than  those  for 
disease.  The  symptom  is  a  very  bad  one.  After  eliminating  any  cause  which 
might  exist  for  a  short  time,  such  as  fright,  the  effects  of  the  anesthetic,  etc., 
if  the  delirium  should  continue  and  increase  in  severity,  a  fatal  prognosis 
would  be  justified.  Delirium  in  disease  is  a  very  common  symptom  with 
children,  the  slightest  fever  being  sufficient  to  cause  it  in  some  instances. 
Being  creatures  of  perception  rather  than  judgment,  the  brain  balance  is 
in  them  readily  disturbed ;  and  if  such  a  trivial  cause  as  a  little  rise  in 
temperature  is  able  to  do  this,  how  great  must  be  the  disturbance  which  may 
follow  a  serious  injury,  combined  with  a  serious  operation.  I  can  give  no 
better  illustration  of  this  than  the  annexed  chart  (Fig.  28)  of  the  history  of 
a  case  of  compound  luxation  of  the  elbow-joint  requiring  excision.  One  may 
see  at  a  glance  how  temperature,  pulse,  and  respiration,  moved  nearly  'pari 
passu  until  the  tenth  day  ;  then,  exhaustion  following  the  intense  excitement, 
there  was  great  recession,  with  chill,  after  which,  new  force  being  gathered, 
the  delirium  became  more  violent,  and  only  ceased  with  the  collapse  of  death. 
Surgical  or  traumatic  fever  is  very  apt  to  be  accompanied  with  delirium. 
By  this  term  I  mean  that  fever  which  is  almost  a  necessary  consequence  of 

1  Pennsylvania  Hospital  Reports,  1869. 

vol.  i. — 25 


386 


TRAUMATIC   DELIRIUM   AND   DELIRIUM    TREMENS. 


great  operations  or  severe  injuries,  such  as  compound  fractures.  The  phrase 
is  often  inadvertently  used  for  the  fever  of  the  various  septicaemias.  This  is 
wrong,  for  there  is  nothing  of  a  septic  character  analogous  to  those  conditions 
about  it.     The  phenomena  of  fever  are  set  up  from  the  great  local  irritation. 

Fig.  28. 


e 

P 

Aug. 

30 
31 

80 

a 

o 

03 

Temperature. 

98    99     100    101    102    103    104    105    106    107 
_•  »  •  i     i  .  •  i  ,  \  i  \      i  i  i  i   i  i  i  i   iii.   j  i  i  •   iiii   .ill 

■ 

M. 

20 

E. 

75 

85 

18 

18 

M. 

E. 

~M.~ 

~ET 

~m7 

e7 

~m7 

Sept. 
1 

2 
3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

75 

80 

85 
105 
104~ 
106 
124 

ii6~ 

125 
143" 

18 

18 

22 

"28 

40 

34 

36 
40 
38 
42 

E. 

M. 

"E. 

M. 

-+- 

I.I. 

.tJ.U, 

■  i  i  i 

ill! 

—  ,   -*- 

j-l  .  i 

!  1  J  I 

E. 

118   36 

M. 

140 

44 

. 

E. 

~w. 

"e7 
M. 

~ E 

80 
120 
112" 

32 
38 

± 

38 

— — ~ 

_ 

120 

124" 

120" 

116 

120 

140T 

150 

156 

130" 

32 
32 

40 



^^ 

M. 

E. 

M. 

~E. 

M. 

E. 

24 
40 
38 

44 

44  ~ 

+■ 

1/ 

, 

. 

M. 

iii. 

,  ,  1  1 

1  '..L.I 

l  l  1  1 

•I  J  j.l 

E. 

13 
14 
15 

L36 
165 
142 
L64 
L56 

46 

IJ 

44 
46 
44 

' 

'   - 

+' 

E. 

M. 

E. 

38 

" 

M. 

..iii 

i  i  i  i 

.ill 

i  i  i 

.III 

ill, 

i  .1  1  . 

'  I-'  1 

mi" 

E. 

98     99     100    101    102    103    104    105    106    107 

Temperature  chart  of  M.  N.,  aged  10.  Traumatic  delirium  following  excision  of  elbow  for 
compound  dislocation.  The  (4-)  indicates  a  rise  of  temperature  after  a  chill.  The  operation 
was  performed  mi  August  30,  1880.  The  delirium,  which  began  on  September  4  (sixth  day) 
and  persisted  until  the  patient's  death,  was  throughout  very  noisy  and  violent,  with  distressing 
hallucinations.  The  treatment  consisted  in  the  administration  of  bromide  of  potassium,  morphia, 
ami  assafcetida. 

Temperature  rises,  as  docs  also  the. pulse;  possibly  there  is  an  accumulation 
of  combustible  products.  The  quickened  circulation  and  the  heated  blood 
play  upon   the  gray   cells   of  the  cortex,  and  hallucinations   and   delirium 


CAUSES    OF   TRAUMATIC    DELIRIUM.  387 

are  the  consequence,  the  vagaries  not  unfrcquently  having  reference  to  the 
functions  of  the  affected  part.  These  symptoms  mostly* subside  after  active 
suppuration  has  been  established,  but  sometimes  death  occurs  before  this 
happens.  How  truthfully  a  case  of  this  kind  is  described  by  Dr.  John  Brown, 
in  "Rab  and  and  his  Friends." 

"Ailie's  right  breast  had  been  amputated — one  night  she  had  fallen  quiet,  and  as  we 
hoped  asleep  ;  her  eyes  were  shut.  We  put  down  the  gas  and  sat  watching  her.  Suddenly 
she  sat  up  in  bed,  and  taking  a  bed-gown  which  was  lying  on  it  rolled  up,  she  held  it 
eagerly  to  her  breast — to  the  right  side.  We  could  see  her  eyes  bright  with  surprising 
tenderness  and  joy,  bending  over  this  bundle  of  clothes.  She  held  it  as  a  woman  holds 
her  sucking  child  ;  opening  out  her  night-gown  impatiently,  and  holding  it  close  and 
brooding  over  it,  and  murmuring  foolish  little  words  as  over  one  whom  his  mother 
comforteth,  and  who  sucks  and  is  satisfied.  It  was  pitiful  and  strange  to  see  her  wasted, 
dying  look,  keen  and  yet  vague — her  immense  love.  '  Preserve  me  !'  groaned  James, 
giving  way.  And  then  she  rocked  backward  and  forward,  as  if  to  make  it  sleep,  hush- 
ing it,  and  wasting  on  it  her  infinite  fondness  '  Wae's  me,  doctor ;  I  declare  she's 
thinking  it's  that  bairn.'  •  What  bairn  ?'  ■  The  only  bairn  we  ever  had,  our  wee 
Mysie  ;  and  she's  in  the  kingdom  forty  years  and  mair  '  It  was  plainly  true;  the  pain 
in  the  breast  telling  its  urgent  story  to  a  bewildered,  ruined  brain,  was  misread  and 
mistaken  ;  it  suggested  to  her  the  uneasiness  of  a  breast  full  of  milk,  and  then  the 
child ;  and  so  again  once  more  they  were  together,  and  she  had  her  ain  sweet  Mysie 
in  her  bosom." 

The  record  of  a  favorable  case  of  surgical  fever  with  traumatic  delirium, 
after  operation,  is  here  presented.  (Fig.  29.)  The  age  of  this  man  had 
doubtless  something  to  do  with  the  symptoms,  for  it  should  be  noted  that 
persons  over  65  or  70  years  old  are  almost  if  not  quite  as  liable  to  be  affected 
with  delirium,  after  great  injuries  or  operations,  as  children.  The  form  of 
delirium  is  generally  like  that  set  down  in  the  chart. 

Independently  of  operations,  compound  fractures  are  very  apt  to  be  accom- 
panied by  delirium,  after  a  few  days  from  the  time  of  the  accident.  Fortu- 
nately, except  in  cases  complicated  with  the  effects  of  drink,  which  will  be 
considered  under  the  head  of  delirium  tremens,  the  delirium  is  not  apt  to  be 
violent,  at  least  in  adults.  During  febrile  exacerbation,  it  takes  the  form  of 
mild  wandering,  which  is  not  accompanied  by  uncontrollable  acts.  It  may 
be  that  the  local  injury  is  a  constant  reminder,  through  pain  inflicted  by  move- 
ment, and  that  thus  the  judgment  is  enabled,  in  a  marked  degree,  to  control  the 
wandering  senses.  This  form  of  delirium  is  not  at  all  serious  in  its  import. 
It  gradually  subsides,  and  is  not  apt  to  return  without  some  extraordinary 
cause.  As  in  almost  everything  else,  the  patient  becomes  accustomed  to  his 
own  condition  and  to  his  surroundings.  Then  fever  may  occur,  as,  for  ex- 
ample, during  the  separation  of  a  piece  of  bone,  but  the  brain  will  be  wholly 
indifferent  to  it. 

Simple  fractures  in  the  old  not  un  frequently  give  rise  to  delirium,  which  is 
also  not  violent  in  form,  but  much  more  serious  in  its  indications  than  that 
which  I  have  just  described.  Senile  delirium  is  always  a  bad  symptom  in 
surgical  cases,  especially  so  when  comparatively  simple  causes  give  rise  to  it. 
It  indicates  an  inherent  Weakness,  not  only  in  the  brain  itself,  which  is  pro- 
bably affected  by  reason  of  deterioration  of  its  bloodvessels,  but  also  in  other 
important  structures,  which  are  undergoing  the  alterations  of  age. 

Extensive  lacerated  wounds  will  often  give  rise  to  delirium,  which  may  last 
but  a  short  time,  the  accompanying  fever  being  ephemeral  in  character  and 
scarcely  worthy  the  title  of  surgical  fever.  I  have  the  chart  of  such  a  case, 
which  gives  the  record  of  what  followed  a  lacerated  wound  of  the  forearm 
in  a  woman  38  years  of  age.  On  the  day  of  the  accident,  the  temperature 
rose  from  98|-°  to  103|°  F.     On  the  third  day,  104°  F.  was  recorded  in  the 


388 


TRAUMATIC    DELIRIUM   AND   DELIRIUM   TREMENS. 


evening.      After   this  there  was  a  recession,  and  the  normal  standard  was 
reached  on  the  ninth  day.     There  was  passive  delirium  at  night,  but  the 

Fig.  29. 


c 

"3 

u 
p. 

Temperature. 

Remarks. 

98           99           100         101            102 
r  .  I  l       iiii       Li.i_.-j       i_i_ jl_l 

July 

27 

28 

29 
30 
31 

1 

M. 
E. 
M. 
E. 

1 

Constant  mild 
delirium,  night 
and  day,  rather 
passive  in  cha- 
racter, taking 
the  form  of  hal- 
lucinations as 
to  locality,  oc- 
cupation, and 
surrounding 
objects. 

98 
90 

20 
24 

92 

~88~ 

26 

24 

^ 

M. 

90 
80 

24 

22 

\ 

E. 

M 
E. 

"mT 

E. 

^ 

85 
~98~ 

24 

22 

— 

95 

24 

^" 

Aug. 
1 

2 

85 

24 

^ 

M. 

90 

86 

80 

26 

E. 

M. 

E. 

24 
~2-T 

1      1    i    -1 

3 
4 
5 
6 

7 
8 

60 
84 
80 

22 
24 

M.  ! 
E- 

22 

M. 
E. 
M. 

84 

~85~ 

24 

20 

85 

20 

E. 
M. 

E. 

80 

85 
80 

84 
~8lT 

18 
18 

18 
18 

M. 
~E. 

~mT 

E. 

m". 

K 

18 

88 

18 

9 

sf, 

18 

80 

IS 

___5 

'   > 

____._■_!_ 

1      I    1      i 

,   j  r_  >___ 

10 

80 
84 

18 

M. 
E. 

-   i 

■  i 

r     .    1     1 

98           99           100           101          102 

Temperature  chart  of  J.  A.,  aged  67.  Traumatic  delirium  following  amputation  of  hand  for 
machine  injury.  Treatment  consisted  in  the  administration  of  20  grains  of  bromide  of  potassium 
with  5  drops  of  the  tincture  of  digitalis  every  four  hours,  and  the  hypodermic  injection  of  a 
quarter  of  a  grain  of  morphia  at  night.     Recovery. 

patient  was  rational  in  the  daytime.  Throughout,  the  wound  was  doing 
well,  and  a  rapid  recovery  ensued.  Such  favorable  progress  of  lacerated 
wounds  is  aot,  however,  always  to  be  looked  for,  when  as  high  temperatures 
as  104°  V.  are  found  to  exist.  One  would  reasonably  fear  an  excess  of  inflam- 
matory action,  which  might  he  followed  by  gangrene.  The  sudden  rise  in 
the  above  case  is  a  matter  of  note,  for,  instead  of  being  alarming,  it,  with  the 
delirium,  simply  pointed  to  the  fact  that  the  patient,  although  an  adult,  had 
the  susceptibility  of  a  child.  There  was  nothing  about  the  wound  to  account 
for  it.  Lacerated  wounds  in  their  ordinary  progress  may  be  the  causes  of 
true  surgical  fever,  with  accompanying  delirium. 


CAUSES   OF   TRAUMATIC    DELIRIUM. 


389 


Bums  and  scalds  are  probably  more  apt  to  be  attended  with  delirium  than 
any  other  class  of  injuries.  In  rapidly  fatal  cases,  where  there  is  no  reaction 
from  shock,  the  brain  is  generally  clear,  and  remains  so  until  death.  During 
this  time,  all  susceptibility  to  pain  having  been  lost,  and  the  sense  of  touch 
being  gone  through  the  destruction  of  its  principal  organ,  the  skin,  the  intel- 
ligence takes  no  cognizance  of  the  vast  calamity.  I  have  seen,  after  deep  and 
extensive  burns,  what  seemed  to  be  a  living  soul  looking  out  of  a  crisp, 
charred,  and  dead  body.  I  have  seen  a  child  thus  burnt  playing  with  toys  an 
hour  before  its  death.  Sometimes,  in  this  condition,  there  is  what  appears  to 
be  a  pleasant  and  mild  delirium. 

"  Death  having  preyed  upon  the  outward  parts, 
Leaves  them  insensible  ;  and  his  siege  is  now 
Against  the  mind,  the  which  he  pricks  and  wounds 
With  many  legions  of  strange  fantasies  ; 
Which  in  their  throng  and  press  to  that  last  hold, 
Confound  themselves.     'Tis  strange  that  death  should  sing." 

A  much  greater  mercy  is  extended  to  these  than  to  those  whose  burns  are 
inevitably  fatal,  and  yet  who  survive  the  shock  for  days,  weeks,  and  it  may 

Fig.  30. 


6 
ft 

"3 

Ph 

a 
.2 

'5, 
a 

K 

Temperature. 

97          98           99           100         101,         102           103         104         105 

May 
11 

12 

84 

33 

1 

M. 

E.~~ 

M. 

~ET 

m7 

E. 
M. 
E. 
M. 
E. 
M. 
E. 

=m 

E. 

M. 

90 
110 

30 
40 

13 

128 
124  ~ 

38 
40 

14 

118 

40 

110 

35 

15 
16 
17 

110 

ioir 

24 

28 

100 
120 
108 

26 

y 

30 
30 

\ 

^ 

1 

125  |  36 

Till 

1111 

iiii 

1     1      1      1 

^     ,                 ' 

1111 

18 
19 
20 
21 

22 

98 
103 

25 

~28~ 

E. 
M7 
E. 
M. 
E. 
~MT 
E. 
M. 
E. 

100 
100~ 
95 
112 
105~ 
120 

24 

30 
23 

30 
32 

86 

. 

t 

90  |  32 
120      40 

;    :    ;    ' 

1       r      ,      , 

1     !    11 

Till 

111, 

,     "^~"~ 

- 

97           98            9a           100          101          102         103          10 

4         1C 

5 

Temperature  chart  of  E.  K.,  aged  37.  Traumatic  delirium  following  extensive  burns  of  face, 
neck,  arms,  hands,  and  trunk,  involving  skin  and  superficial  fascia.  From  May  14  until  the 
patient's  death,  the  delirium  was  active  and  constant,  requiring  mechanical  restraint.  The 
treatment  consisted  in  the  administration  of  20  grains  of  bromide  of  potassium,  with  10  grains 
of  chloral  hydrate,  aud  5  drops  of  the  tincture  of  digitalis,  every  four  hours. 


m 


TRAUMATIC    DELIRIUM    AND    DELIRIUM    TREMENS. 


be  for  months.  Is  it  any  wonder  that  these  patients  all  become  delirious, 
and  that  in  some  the  symptom  is  continuous  until  the  end  ?  Those  who  re- 
cover, also  have  delirium,  which  varies  in  extent  and  duration  with  the 
severity  of  the  injuries.  Touch,  the  master  sense,  of  which  all  other  special 
senses  are  modifications,  and  without  which  no  knowledge  of  the  external 
world  is  conceivable,  is  terribly  deranged,  and  expresses  itself  to  the  sensor- 
ium  only  as  pain.  Myriads  of  fibres  as  conveyers,  myriads  of  cells  as  receivers, 
are  involved.  There  is  so  much  wrong  at  the  surface,  that  it  would  be  a 
marvel  if  wrong  did  not  follow  at  the  centre.  I  should  much  sooner  expect 
to  find  irritative  exudations  on  the  posterior  surfaces  of  the  cortex  in  fatal 
burns,  than  ulcers  in  the  duodenum. 

Besides  pain,  as  a  producer  of  delirium  in  burns,  surgical  fever,  with  its 
ordinary  phenomena,  may  also  set  in  and  develop  it.  This,  however,  is  not 
often  the  case,  for  it  is  surprising  to  notice,  after  the  surfaces  have  become 
clean  and  the  papillae  well  covered  wTith  healthy  granulations,  how  tolerant 
the  patient  becomes ;  and  when  repair  is  fully  in  progress,  he  passes  on  to  a 
slow  recovery  without  any  mental  disturbance. 

I  have  the  charts  of  six  burnt  and  scalded  patients  before  me,  all  of  whom 
had  delirium.  Four  of  these  recovered  and  two  died.  One  of  the  fatal  cases 
illustrates  a  burn  and  the  other  a  scald.     These  two  charts  (Figs.  30,  31;  are 

Fi£.  31. 


Pi 

0 

O 

3 
P. 

Temperature. 

Pi  9 
.1  |.| 

100 

i      i   i 

101 
1  1   1 

102     103 

104 

105 

106 

Aug. 
12 

13 
14 

100 
119 
116 
~T04 
114 

20 

M. 

"e7 

20 
18 

~T8~ 

2d 

M. 

~E.~ 
M. 
E. 
M. 
E. 
M. 

"eT 

M. 

E. 

15 
1G 
17 

18 

116 

ioii 

106 
1114 
106 

20 

"20 

18 

To 

22 

^s 

116 
110 

22 
22 

M. 
E. 

120 

24 

_1  1  1  1 

1  ■ }   ■  ' 

iiii 

i  i  i  i 

19 

120 
126 

26 

' ' '    -^ 

M. 

E. 

30 

Aj 

, , 

t,,1 

kJ  >~ 

99 

100 

101 

1( 

)2    1 

33 

104 

105 

106 

Temperature  chart  of  P.  M.,  aged  23.  Traumatic  delirium  following  scalds  of  face,  neck, 
forearms,  hands,  and  air-passages  (by  inhalation).  Violent  raving  delirium  began  on  August 
13  (second  day),  and  continued  day  and  night,  until  the  patient's  death,  requiring  mechanical 
restraint.  The  treatment  consisted  in  the  administration  of  30  grains  of  bromide  of  potassium 
with  10  drops  of  the  tincture  of  digitalis  every  (our  hours  ;  of  10  grains  of  chloral  hydrate  every 
six  hours  ;   and  of  half  a  grain  of  morphia,  hypodermically,  at  night. 

annexed,  as  well  as  one  (Fig.  32)  of  recovery  from  burn.  In  two,  the  delirium 
Bel  in  on  the  second,  and  in  the  other  on  (he  fourth  day,  certainly  too  soon  I 
think  in  all  of  them,  and  at  least  in  the  first  two,  for  ordinary  surgical  fever. 
There  was  no  delirium   tremens  in  these  cases.     The  absolute  and  cpiick  de- 


CAUSES   OF   TRAUMATIC    DELIRIUM. 


391 


struction  of  the  papillary  surface  of  the  derm  is  not  so  apt  to  take  place  in 
fatal  scalds,  as  in  fatal  burns.  Hence  a  sudden  delirium  in  the  former  may 
subside,  after  complete  insensibility  of  the  part  occurs. 

Erysipelas  is  a  fruitful  source  of  delirium.  Place  and  extent  have  their  in- 
fluences in  producing  it.  When  the  disease  is  in  the  face  and  scalp,  active 
delirium  may  set  in  very  promptly.  There  is  no  doubt,  I  think,  that  con- 
tiguity and  similar  blood  supply,  giving  rise  to  meningeal  congestions,  have 

Fig.  32. 


'a 

ft 

"3 

Ph 

a 

o 

"3 

'p. 

Temperature. 

97    98     99     100    101    102    103    104    105 

May 
29 

80  [  20 
~92~|-i8~ 

M. 

E. 
M. 

30 

31 

June 
1 

2 
3 
4 
5 
6 
7 
8 
9 
10 

100  |  22 

102 

88 

30 

E. 
M. 

24 

100 

100~ 

122 

100 

108 

118 

28 

— 

E. 

30 

28 

M. 
E. 
M. 

E. 

"m7 

E. 

M. 

~eT 

- 

24 
28 
30 

118 

32 

122   24 

120 

31 

90 
102 

20 
20 

M. 

E. 

100 

24 

M. 

~9lT|~23~ 

^ 

E. 

96 

~20~ 

"-— -. 

M. 

106 
~W 

88 
86 

~28~ 
24 
20 

y 

M. 
E. 

M. 

E. 

20 

78 
76 

22 
~18~ 

M. 

86 

22 

iiii 

>   1   7   1 

1111 

lit, 

f  i  >  i 

E. 

97     98     99     100    101    102    103    104    105 

Temperature  chart  of  L.  J.,  aged  21.  Traumatic  delirium  following  superficial  and  deep  burns 
of  face,  neck,  arms,  forearms,  hands,  legs,  and  feet.  From  May  30  (second  day)  to  June  6  (ninth 
aay)  there  was  delirium,  mild  during  the  day,  but  noisy  and  requiring  mechanical  restraint  at 
night.  The  patient  was  rational  on  June  8.  The  treatment  consisted  in  the  administration  of  30 
grains  of  bromide  of  potassium  every  five  hours,  with  15  grains  of  chloral  hydrate  at  night  and 
a  quarter  c*  a  grain  of  morphia  when  required.     Recovery. 

much  to  do  with  the  production  of  delirium  under  these  circumstances,  and 
that  in  the  early  stage  the  brain  is  more  irritated  by  these  conditions  than 
by  the  presence  of  any  specific  poisonous  products.  It  is  at  such  times  that 
blood-letting,  if  resorted  to  at  all,  is  admissible.  When  much  surface  is  in- 
volved by  erysipelas,  in  other  portions  of  the  body,  we  have  conditions  analo- 
gous to  those  of  an  extensive  superficial  burn,  and,  as  a  consequence,  delirium, 
generally  of  an  active  character,  is  produced.     In  phlegmonous  erysipelas, 


392  TRAUMATIC    DELIRIUM    AND   DELIRIUM    TREMENS. 

where  the  cellular  tissue  besides  the  skin  is  the  seat  of  great  inflammation 
and  destruction,  the  blood  no  doubt  becomes  loaded  with  septic  materials. 
Delirium,  often  very  wild  at  first,  is  not  uncommon.  If  the  case  is  to  end 
fatally,  a  state  very  like  that  of  pyaemia  is  developed,  and,  as  the  patient 
grows  weaker,  the  disordered,  brain  expresses  itself  in  low,  indistinct  and 
unmeaning  mutterings. 

Epileptic  patients,  becoming  the  subjects  of  injury,  are  not,  according  to  my 
observation,  more  prone  to  delirium  than  others.  In  fact,  I  have  seen  some 
cases  in  which  the  brain  irritability  appeared,  to  be  arrested  or  suspended 
for  a  time  by  reason  of  casualty.  Whilst  writing  this  article,  a  rare  and 
curious  case  came  under  observation  in  the  Pennsylvania  Hospital. 

A  man  was  admitted  for  an  accident  requiring  excision  of  tlie  right  elbow-joint.  A 
few  mornings  after  the  operation,  he  was  found  to  be  having  an  attack  of  catalepsy. 
His  eyes  were  open  and  fixed ;  his  head  was  motionless  ;  no  answers  to  questions  were 
given.  One  leg  was  raised  :  it  remained  fixed  and  rigid  in  the  air.  The  same  was  the 
case  with  the  other  leg,  and  also  with  the  left  arm.  Where  they  were  placed,  the  limbs 
stayed  until  they  were  put  down  on  the  bed.  The  mouth  also  could  be  opened  and 
fixed  in  any  position  which  it  was  capable  of  taking.  The  patellar  tendon-reflex  was 
present  in  a  limited  degree,  but  the  groin  or  scrotal  reflex  was  marked.  There  was 
complete  anaesthesia  ;  no  notice  was  taken  of  pins  or  pinchings.  While  I  was  in  the 
ward,  the  man  was  observed  to  turn  his  head  ;  I  went  to  him  ;  he  was  awake,  but  in 
delirium.  This  delirium  expressed  itself  in  delusions  as  to  place.  He  could  give  a 
true  account  of  his  injury,  and  the  name  of  the  railroad  on  the  line  of  which  it  hap- 
pened. He  himself,  however,  was  on  top  of  a  pole  ;  then  in  a  churchyard  ;  then  in  the 
building  of  the  Pennsylvania  Insurance  Company  ;  then  on  top  of  a  railing.  His 
occupation  had  nothing  to  do  with  these  places.  Being  in  the  insurance  company's 
building  might  have  been  suggested  by  his  being  told  that  he  was  in  the  Pennsylvania 
Hospital.  The  attack  soon  passed  off,  and  on  the  third  day  the  patient  was  entirely 
himself.  He  said  that  he  had  been  subject  to  vivid  and  troublesome  dreams,  but  both 
he  and  his  wite  declared  that  he  had  never  before  had  a  cataleptic  fit,  at  least  to  their 
knowledge. 

In  hectic,  there  is  no  delirium.  Its  absence,  indeed,  is  the  great  fact  that 
serves  to  distinguish  hectic  from  other  febrile  troubles  which  occur  in  the 
course  of  surgical,  as  well  as  of  medical  cases.  Why  the  cerebral  system  is 
so  exempt  from  contamination  in  hectic  is  difficult  to  explain.  There  are 
continuous  febrile  conditions  with  exacerbations,  many  constant  and  morbid 
tissue  changes  giving  rise  to  products  that  would  seem  to  have  all  the  ele- 
ments about  them  necessary  to  poison  the  blood,  and  so  to  work  damage  on 
the  delicate  cells  of  the  cortex;  there  are  exhausting  discharges;  excruciating 
pains  often,  as  of  the  joints;  colliquative  sweatings  and  skin  irritations 
enono'h  to  set  a  giant  mad,  and  yet  never  an  approach  to  delirium.  This  fact 
is  so  generally  recognized,  that  when  delirium  arises  in  a  hectic  patient, some 
accidental  cause,  as  for  instance  an  intercurrent  erysipelas,  will  be  found  to 
explain  it,  and  when  tliis  is  over  the  usual  course  is  resumed.  The  freedom 
from  delirium  cannot  he  explained  by  assuming  that  tubercular  and  allied 
products  are  non-irritating  in  their  character,  for  when,  as  in  tuberculous 
meningitis,  the  cortex  becomes  directly  concerned,  there  is  marked,  often 
violent  and  continuous,  delirium,  of  a  character  that  suggests  something  pecu- 
liar as  its  cause,and  that  is  not  explained  merely  by  the  local  congestion.  In 
this  disease  also,  there  is  rarely  time  for  the  development  of  hectic.  In  hectic 
it  is  said  I  hat  there  is  no  materies  morbi  introduced  into  the  blood  from  without, 
and  that  the  products  of  tissue  waste  are  carried  oil' by  the  emunctories  with 
such  regularity  and  rapidity,  that  there  is  no  accumulation  of  deleterious 
material  in  the  circulation.  This  is  an  ingenious  explanation,  but  not  alto- 
gether satisfactory.     It  certainly  favors  the  theory  that  causes  giving  rise  to 


DIAGNOSIS   OF   TRAUMATIC   DELIRIUM.  S93 

hectic  are  local  in  their  origin,  and  are  not  due  to  antecedent  blood  contami- 
nations. It  also  helps  to  sustain  the  view  that  other  febrile  conditions,  as 
the  septicaemias,  must  have  peculiar  causes  to  originate  them,  these  generally 
arising  from  without  in  the  shape  of  organic  germs,  or  animal  poisons. 

It  is  in  cases  of  this  latter  kind  that  we  do  have  delirium,  and  their  num- 
ber is  probably  greater  than  that  of  any  other  class  in  medicine  and  surgery. 
It  is  certainly  so  during  wars  and  pestilence.  Badly  ventilated  and  crowded 
tenements;  poorly  constructed  hospitals  ;  abodes  of  any  kind  presenting  errors 
in  drainage,  in  sewerage,  in  location  (as  of  camps);  wherever,  in  fact,  masses 
of  men  are  brought  together,  under  unfavorable,  and  sometimes  in  apparently 
favorable,  conditions,  there,  wounds  or  disease  arising,  the  "  pure  brain,  by 
the  idle  comments  that  it  makes,"  too  often  "  foretells  the  ending  of  mortality," 
for  "the  life  of  all  the  blood  is  touched  corruptibly."  Immense  advance  lias 
been  made  of  late  in  checking  the  rise  and  progress  of  these  "  preventible 
diseases."  It  is  too  much  to  believe  that  they  will  eventually  disappear,  for 
the  conditions  for  their  production  are  constantly  arising  anew,  or  are  being 
reproduced  in  places  where  it  was  thought  that  they  had  1  teen  al  tated  or  stamped 
out.  Pycemia,  phlebitis,  low  forms  of  erysipelas,  gangrene,  malignant  pustule, 
phagedena,  carbuncle,  any,  indeed,  of  the  diseases  which  from  their  very  nature 
generate  certain  blood  poisons,  and  produce  febrile  states  analogous  to  those 
called  typhoid  or  typhus,  come  under  this  head.  They  are  truly  classified  as 
blood  poisons,  or  septicemias,  and  when  developed  to  any  extent,  they  one  and 
all  give  rise  to  delirium.  This  delirium  is  sometimes  active,  but  is  mostly  of  a 
passive  character.  When  active,  the  brain  membranes  are  probably  the  seat  of 
local  inflammations,  which  may  arise  early  in  the  disease,  and  which  are  of 
very  serious  significance.  The  high  excitement  may  be  continuous  until  col- 
lapse and  death  occur.  I  have  seen  cases  of  this  kind,  but  they  are  rare. 
Mostly,  days  elapse  before  delirium  becomes  a  prominent  symptom.  It  will 
appear  during  the  febrile  paroxysms,  and  pass  away  with  them.  If  the  case 
goes  on  from  bad  to  worse,  it  will  become  continuous,  and  express  itself  in 
vague  mutterings  as  long  as  the  patient  is  left  to  himself.  lie  will,  however, 
answer  questions  correctly,  and  take  food  without  resistance,  and  sometimes 
with  avidity.  He  soon  lapses,  loses  his  sense  of  locality,  and  "wants  to  go 
home;"  then  he  becomes  altogether  unconscious,  apparently  more  from  exhaus- 
tion than  from  deep  coma,  for  he  babbles  and  mutters  almost  until  he  dies. 
Given  the  conditions,  there  is  scarcely  a  form  of  surgical  affection,  in  itself 
mild  or  severe,  that  may  not  take  on  the  above  characters.  This  is  especially 
true  as  to  all  cases  in  which  there  are  open  or  abraded  surfaces,  either  simple 
or  complicated,  and  this  fact  goes  far  to  sustain  the  germ  theory,  however 
unproved  it  may  be. 

In  such  a  disease  as  cancer,  we  find  that  there  is  no  delirium  in  its  progress, 
that  is,  none  belonging  to  it  because  of  the  cancer;  and  yet  what  is  more 
professionally  and  popularly  thought  to  be  a  peculiarly  infecting  disease  than 
this  ?  As  in  the  case  of  hectic,  there  is  enough  to  produce  delirium,  but  I  do 
not  remember  to  have  seen  a  cancerous  patient  thus  affected.  We  call  the 
disease  malignant,  and  so  it  is;  but  it  rarely  appears  to  express  its  malignancy 
on  the  gray  cells  of  the  cortex. 

Diagnosis  op  Traumatic  Delirium. — Delirium  declares  itself,  and  hence 
there  is  nothing  very  profound  to  be  said  as  to  its  diagnosis.  It  is  the  kind 
that  requires  discrimination,  for  restraint  may  have  to  be  used,  or  else  there 
must  be  great  watchfulness  on  the  part  of  the  attendants.  Ordinary  delirium 
should  be  carefully  distinguished  from  delirium  tremens — a  matter  which  will 
be  discussed  on  a  subsequent  page.  Sometimes  delirium  may  be  assumed. 
He  would  be  a  consummate  malingerer  who  could  keep  up  the  deception  for 


894  TRAUMATIC    DELIRIUM    AND   DELIRIUM    TREMENS. 

any  length  of  time.  The  coincident  febrile  or  other  symptoms  would  be 
wanting,  and,  by  throwing  the  patient  oft'  his  guard,  it  could  very  soon  be 
shown  whether  or  not  he  was  in  his  right  mind.  A  counterfeit  delirium  or 
wildness  sometimes  occurs  in  hysteria,  often  very  difficult  or  impossible  to 
tell  from  the  real  thing.     In  such  cases  time -alone  will  develop  the  truth. 

Treatment  of  Traumatic  Delirium. — Delirium  being  a  symptom,  its 
treatment  naturally  consists  in  measures  to  remove  the  cause.  In  by  far  tbe 
greater  number  of  surgical  cases,  where  it  exists,  this  is  the  course  pursued. 
Sometimes,  however,  the  symptom  becomes  so  prominent,  and  so  disturbing 
to  what  is  being  done  for  the  main  affection,  that  especial  means  are  required 
to  allay  it.  Indeed  it  is  not  uncommon  to  have  to  almost,  if  not  altogether, 
abandon  the  original  treatment  for  a  while,  and  to  address  remedial  measures 
wholly  to  the  delirium.  In  the  very  active  forms,  cupping  on  the  back  of 
the  neck,  cold  by  ice-bags  to  the  head,  and  free  purgation  with  salines  are 
required.  Hot  mustard  foot  baths  are  of  great  use,  and  may  be  readily  given 
to  the  patient  while  lying  in  bed,  should  there  be  no  surgical  disability  of  the 
lower  extremities.  The  bromide  of  potassium,  or  other  bromides,  may  be 
administered  in  large  doses.  Opium  is  too  much  feared,  and  certainly  should 
not  be  discarded  altogether,  as  is  done  by  some  surgeons.  Chloral  hydrate  is 
also  of  great  use.  Sometimes  the  necessities  of  the  case  may  call  for  the  use 
of  ether  or  chloroform  by  inhalation.  In  the  passive  forms  of  delirium,  re- 
quiring interference,  depleting  measures  are  not  well  borne.  Good  nourish- 
ment and  stimulants,  together  with  moderate  doses  of  opium,  will  be  found 
to  allay  the  violence,  if  not  entirely  to  prevent  the  occurrence,  of  the  symptom 
in  ordinary  cases.  Of  course,  nothing  is  to  be  gained  by  directing  remedies 
especially  to  the  delirium  immediately  preceding  death,  unless  it  should  be 
very  violent,  which  is  not  common.  At  the  beginning  of  delirium,  quiet,  as 
absolute  as  possible,  and  isolation,  are  great  factors  for  good.  There  should 
be  no  suggestive  conversations  with  the  patient,  or  with  others  in  his  hearing, 
for  these  might  readily  lead  to  unfortunate  acts.  A  statement,  interesting  in 
this  connection,  bas  been  recently  published  in  the  medical  journals.  The 
delirious  patients  of  one  doctor,  in  a  hospital,  were  found  to  have  a  great 
propensity  to  throw  themselves  out  of  the  windows,  and  had  to  be  carefully 
watched.  The  other  doctors'  patients  were  free  from  this  tendency.  A  medi- 
cal man  was  taken  sick  in  the  hospital,  and  became  delirious.  He  was  under 
the  care  of  the  first  doctor.  He  reported  afterwards  that  this  doctor  was  in 
the  habit  of  giving  directions  about  guarding  the  windows,  in  the  hearing  of 
bis  patients.  The  sick  man  went  through  the  same  experience,  and  declared 
that,  during  his  delirium,  the  impulse  to  throw  himself  from  the  window 
was  so  irresistible,  that  he  would  have  done  so  had  he  not  been  guarded. 


Delirium  Tremens. 

In  a  "tract"  upon  this  subject,  written  "by  Thomas  Sutton,  M.D.,  of  tbe 
Royal  College  of  Physicians,  and  Physician  to  the  Forces"  (London,  1813), 
the  author  says:  "  Delirium  tremens,  and  likewise  the  treatment,  which  will 
be  pointed  qui  as  we  proceed,  are  known  to  some  professional  men  to  a  cer- 
tain extent;  but  to  many  they  are  wholly  unknown  ;  and  the  disease  has  not 
ye1  taken  a  station  in  medical  writings."  In  his  practice  between  1798  and 
1807,  the  doctor  "  was  led  to  see  the  distinction  between  phrenitis  and  de- 
lirium tremens,  at  least  in  regard  to  the  treatment." 

,  These  remarks  are  introduced  to  show  how  comparatively  late  in  the  his- 
tory of  medicine,  a  distinctive  recognition  was  made  between  meningitis  or 


CAUSES    OF    DELIRIUM    TREMENS.  395 

plirenitis,  and  delirium  tremens,  the  latter  having  for  its  production  a  specific 
cause,  and  a  pathological  anatomy  entirely  distinct  from  that  of  the  former. 
From  the  earliest  times,  excess  in  drink  has  been  a  habit  among  men,  and 
it  seems  scarcely  credible  that  the  efiects  of  this  habit  in  producing  a  pecu- 
liar disease  of  the  brain  and  its  membranes,  should  for  so  long  a  time  have 
escaped  attention.  AVas  it  because  everybody  drank,  and  was  drinking 
considered  so  innocent  a  pastime  that  it  was  not  thought  of  as  a  cause  of 
disease  ?  This  also  is  incredible,  for  the  evils  of  drink,  as  well  as  its  pleasures, 
are  dilated  upon  by  the  authors  of  all  ages  and  countries.  It  is  probable 
therefore  that  drink  was  known  to  be  a  cause  of  disease,  but  that  the  efiects 
were  misinterpreted,  and  were  considered  to  be  evidences  of  active  inflamma- 
tion. This  was  no  doubt  so,  for  the  treatment  of  these  cases  was  antiphlogis- 
tic to  an  extreme  degree,  and  the  mortality  was  frightful.  A  great  advance, 
then,  was  made  when  it  was  recognized,  both  by  the  efiects  of  treatment  and  by 
the  results  of  post-mortem  examinations,  that  a  true  inflammation  did  not 
exist  in  this  disease.  Dr.  Sutton  was  at  first  on  the  plirenitis  side.  He 
naively  says  :  "  The  one  party,  with  myself,  considering  the  disorder  to  be 
active  inflammation  of  the  brain  or  its  investing  membranes,  conducted  the 
treatment  according  to  this  supposition  ;  the  other,  without  pretending  to 
any  precise  notions  of  this  affection,  in  so  far  as  the  contents  of  the  cranium 
might  be  concerned,  were  in  the  habit  of  using  opium  in  large  and  repeated 
doses.  /  very  soon  perceived  that  the  latter  practice  carried  with  it  all  the  suc- 
cess" 

The  post-mortem  appearances,  as  far  as  the  contents  of  the  cranium  are  con- 
cerned, are  peculiar  in  this,  that  they  showT  no  sign  of  active  inflammation, 
nor  of  any  of  its  products.  Instead  of  adhering  membranes,  thickenings,  opa- 
cities, and  pus,  there  is  a  condition,  so  characteristic  in  uncomplicated  cases, 
that  it  has  been  named  "  wet  brain."  Passive  congestion  and  serosity,  the 
latter  both  subarachnoid,  in  and  under  the  pia  mater,  and  filling  the  ventricles 
and  following  the  convolutions,  are  what  are  met  with.  The  brain  substance 
proper  is  not  necessarily  the  seat  of  changes  ;  and  what  happens  to  it  in  fatal 
cases  must  be  secondary,  and  not  essential  to  the  disease,  else  how  could  it 
be  possible  for  so  many  to  recover  entirely  from  this  affection,  and,  provided 
that  there  be  no  return  to  former  habits,  to  pass  their  lives  without  showing 
any  defect  in  mind  or  body  ?  In  fact,  what  was  said  about  traumatic  delirium 
and  delirium  in  general,  is  equally  applicable  here.  A  sound  cortex,  capable 
of  being  impressed  by  adverse  influences,  is  in  the  best  state  to  develop  de- 
lirium. Repeated  drafts  upon  this  soundness,  by  renewed  attacks,  will  finally 
affect  it,  and  the  victim  will  then  too  often  lapse  into  imbecility  or  dementia. 

Causes  of  Delirium  Tremens. — Delirium  tremens  then,  as  far  as  its  pro- 
duction is  concerned,  does  not  differ  from  other  forms  of  delirium.  The  dif- 
ference lies  in  the  peculiar  effects  arising  from  the  cause.  The  great  interest 
of  medical  men  in  this  disease  is  due  to  its  frequency,  through  the  universal 
prevalence  of  drinking  habits.  There  is  no  disease  or  injury  upon  which  it 
may  not  make  its  imprint,  and  give  a  serious  turn  to  what  would  otherwise 
be  favorable.  In  many  cases,  both  medical  and  surgical,  all  else  has  to  be 
abandoned  in  treatment  until  the  delirium  is  subdued.  Thus  delirium  tre- 
mens is  not  only  a  torment  in  itself,  but,  when  it  complicates  other  affeetionsy 
it  is  an  unbounded  torment  to  all  concerned. 

The  cause  is  nearly  always  the  excessive  use  of  alcoholic  drinks.  The 
habitual  use  of  other  articles  is  said  to  produce  it:  opium,  belladonna,  stra- 
monium, tobacco,  cannabis  indica,  certain  fungi,  and  even  tea  and  coffee  are 
all  capable  of  causing  delirium.     Of  these,  it  is  said  that  veritable  delirium 


396  TRAUMATIC    DELIRIUM   AND   DELIRIUM    TREMENS. 

tremens  is  sometimes  produced  by  opium  and  tobacco,  and  cases  may  be  found 
in  medical  works  in  proof  of  the  fact.  I  have  seen  one  case  of  poisoning  with 
stramonium.  There  were  hallucinations  and  much  severe  delirium,  with 
visual  anomalies,  but,  the  cause  being  well  known,  the  symptoms  soon  sub- 
sided under  treatment  with  emetics.  Overdoses  of  belladonna  produce  like 
effects,  and  sometimes  there  is  furious  delirium.  It  is  not  common  for  either 
of  the  two  last-mentioned  drugs  to  be  used  habitually  ;  a  necessity,  it  would 
seem,  for  the  production  of  delirium  tremens  by  any  substance  capable  of 
causing  it.  Cannabis  indica  is  habitually  used  in  the  East,  mostly  in  the  form 
of  the  well-known  haschish.  It  is  said  "  to  pervert  the  natural  perception  of 
objects  and  their  normal  conditions  and  relations,  more  than  an}^  other  agent." 
If  so,  one  would  think  that  in  time  phenomena  like  those  of  delirium  tremens 
might  readily  follow  its  use.  I  have  one  observation  to  record  as  to  its  curious 
power  of  producing  double  consciousness,  an  alter  ego.  I  was  giving  it  to  a 
patient  for  some  chest  trouble.  He  was  wholly  ignorant  of  what  he  was 
taking.  One  day  he  said  to  me  :  "  Doctor,  you  will  have  to  stop  giving  me 
that  medicine ;  I  don't  know  what  it  is,  but  here  am  I,  John,  on  this  lounge, 
talking  to  myself,  John,  sitting  on  that  chair.  I  can't  stand  it,  and  if  you 
keep  on  I  shall  be  wild."  The  symptom  disappeared  on  discontinuing  the 
medicine.  Had  one  side  of  the  brain  the  power  to  so  project  an  ego,  that  the 
other  side  could  take  cognizance  of  it  ?  Singleness  as  to  both  external  objects 
and  ideas,  seems  to  be  the  result  of  the  actions  of  our  double  cerebral  organs, 
or  centres,  in  a  normal  condition.  When  perverted  by  disease  or  intoxicating 
agents,  this  particular  property  might  be  disturbed,  and  such  curious  results 
as  that  just  related  might  be  produced.  Anaesthetics,  such  as  ether  and 
chloroform,  it  is  well  known  sometimes  cause  violent  delirium.  This  may 
occur  at  the  start,  and  not  return,  but  now  and  then  a  case  is  met  with  in 
which  delirium  persists  after  an  operation  has  been  performed.  I  have  known 
it  to  so  continue,  and  to  be  apparently  the  exciting  cause  of  an  attack  of  de- 
lirium tremens,  of  which  the  remote  and  continuing  occasion  was  an  under 
stratum  of  rum. 

It  is  not  my  intention  to  consider  here  all  substances  that  might  possibly 
cause  delirium  tremens.  The  above-mentioned  are  the  most  prominent. 
For  practical  purposes,  delirium  tremens  caused  by  the  habitual  use  of  alco- 
holic drinks  is  what  demands  the  attention  of  the  surgeon.  The  disease,  as 
proved  from  post-mortem  examinations,  and  also  from  the  results  of  various 
modes  of  treatment,  is  one  of  depression  of  the  organic  forces,  although  it 
may  express  itself  by  intense  animal  excitement,  and  hence  the  source  of  those 
mistaken  views  already  alluded  to,  which  regarded  it  as  a  true  phrenitis.  It 
is  thought  by  many  to  be  caused  by  the  withdrawal  of  accustomed  stimulus. 
This  may  sometimes  be  so,  but  the  truth  more  likely  lies  in  the  fact  that,  at 
the  time  of  the  attack,  there  is  a  rebellion  of  the  overtaxed  digestive  organs. 
The  stomach  becomes  sickened,  the  liver  refuses  to  act  properly,  the  bowels 
are  torpid,  the  kidneys  are  irregular  in  action  and,  with  "  old  stagers,"  are 
often  so  altered  by  disease  as  to  give  rise  to  temporary  suppression  of  urine. 
Thus  the  various  results  of  vicious  tissue-metamorphosis,  besides  those  of 
alcohol,  to  which  they  also  are  due,  poison  the  blood,  and  produce  through 
the  circulation,  and  probably  by  direct  contact  with  the  cortex,  the  peculiar 
form  of  delirium  under  consideration.  There  is  no  doubt  that  in  many  acci- 
dent-cases, the  sudden  stopping  of  the  drinking  habit  will  develop  the  disease. 
That  is  to  say  that,  without  the  accident,  the  patient  would  not  have  had  the 
attack  ;  but  here  the  casualty  may  itself  have  been  a  prime  cause  of  depres- 
sion, and  thus  have  produced  that  state  which  allows  the  effects  of  the  habit 
to  declare  themselves  and  to  gain  the  upper  hand. 


SYMPTOMS   OF   DELIRIUM    TREMENS. 


397 


Delirium  Tremens  and  Mania  a  Potu. — It  is  important  to  distinguish  be- 
tween delirium  tremens  proper,  and  that  wild,  acute  delirium,  which  is  the 
result  of  a  grand  "  spree,"  the  delirium  ebriosorum,  the  true  mania  a  potu.  The 
surgeon  often  meets  with  these  cases,  as  wounds  of  all  kinds  are  not  unfre- 
quently  received  during  the  debauch.  All  stages  are  exhibited  by  these 
patients,  from  the  "  remorse  that  weeps,  to  the  rage  that  roars."  They  mostly 
require  to  be  kept  from  injuring  themselves  and  others,  until  the  immediate 
effects  of  the  overdoses  of  alcohol  are  over,  when  there  is  rarely  any  difficulty 
in  taking  care  of  them.     Below  is  a  chart  (Fig.  33)  of  a  case  of  this  kind. 

Fig.  33. 


"3 

a 
a 

Temperature. 

97    98     99     100    101     102    103    104    105 

1  1  1  _l 1  i  i  i  .  ,  ,l  1  1  ,   l  ,i,  l  1   .  i   l  ,  l l_i_L_i 1  f  .  f  1 1_1_1_J 

Aug. 
12 

13 
14 
15 
16 
17 
18 
19 
20 
21 

94 
102 
108~ 
116 
106 
102 
106 
101) 

ibo~ 

102~ 

20 
20 
~2T 
22 
20 
18 
124~ 

M. 
E. 
M. 
E. 
M. 
~ET 
M. 
E. 
M. 
E. 

_m7 

E. 
M. 
E. 

N 

'   / 

V 

22 
24 
"20 

106 

ioo 

98 
100 

licT 

104~ 
112 

12CT 
136 

22 

20 

22~ 

22 

24~ 

24 

j  •  '  < 

r  i   i  ? 

r  (  1  1 

1  1  1  1 

rill 

i  1  l'l 

M. 
E. 
M. 
E. 

~m7 

28 

26 
32 

ill! 

till 

TT— -^~J 

i  E- 

97     98     99     100    101    102    103    104    1( 

15 

Temperature  chart  of  H.  M.,  aged  35.  Mania  a  potu  after  scalds  of  face,  neck,  scalp,  fore- 
arms, hands  and  ankles.  This  patient  was  doing  very  well,  though  with  high  temperature, 
until  twenty-four  hours  before  his  death,  when,  his  friends  having  poisoned  him  with  very  bad 
whiskey  which  they  had  smuggled  into  the  hospital,  he  was  attacked  with  mania  a  potu,  and, 
after  a  night  and  a  day  of  the  most  acute,  active  delirium,  died  from  exhaustion.  The  treatment 
consisted  in  the  administration  of  large  doses  of  bromide  of  potassium,  chloral  hydrate,  and  sul- 
phate of  morphia. 

The  cause  given,  the  suddenness  of  the  attack,  and  the  nature  of  the  injuries, 
also  themselves  prone  to  produce  delirium,  mark  it  as  one  of  true  mania  a 
potu.  The  chart  points  almost  with  certainty  to  the  time  when  the  smuggled 
whiskey  begun  its  work  of  death.  The  rise  of  temperature  was  steady," the 
attack  furious,  and  the  termination  rapidly  fatal. 

Symptoms  of  Delirium  Tremens. — The  trembling,  watchful,  wakeful,  sus- 
picious, cowardly,  busy  subject  of  an  attack  of  delirium  tremens,  is  almost 
too  well  known  to  need  description.  His  hallucinations  are  without  number. 
He  sees  rats,  rams,  snakes,  monkeys,  cats,  bats,  bugs,  spiders,  mice,  lice,  imps, 


398  TRAUMATIC   DELIRIUM   AND   DELIRIUM    TREMENS. 

demons  and  furies,  dancers  and  devils — but  not  often  angels,  as  the  illusions 
are  rarely  pleasant.  The}'  are,  however,  sometimes  comical,  frequenly  obscene, 
often  sad,  but  general ly  horrible.  The  patient  is  subject  to  attacks  from 
without,  and  is  constantly  shrinking  from  them,  having  no  courage  to  defend 
himself.  Somebody  or  something  is  going  to  kill  him,  and  fiends  are  doing 
their  best  to  prevent  him  from  attending  to  the  most  important  business, 
with  which  he  is  also  constantly  occupied.  Sometimes  this  business  has  to 
do  with  the  real  occupation  of  the  patient,  at  other  times  it  is  wholly  im- 
aginary. I  have  known  a  teamster,  with  a  bad  fracture,  to  lie  in  bed  and 
drive  his  mules  and  horses  all  day,  with  loud  curses  and  imaginary  lashings. 
A  broker  will  rave  of  the  stocks,  and  a  merchant  of  the  markets;  but  mostly, 
when  sifted,  this  all-important  business  will  be  found  to  be  about  the  most 
trivial  and  absurd  matters.  Not  unfrequently,  and  especially  in  the  begin- 
ning, the  delusions  are  only  about  one  thing,  or  upon  one  subject ;  thus,  an 
officer  who  had  been  through  the  late  war,  was  perfectly  straight  as  to  every- 
body and  everything  else  about  him,  except  a  long  tin  foot-warmer,  which 
had  been  placed  at  his  feet  in  bed  and  covered  up.  The  mound  thus  made 
suggested  a  body  and  a  coffin,  and  it  was  at  once  converted  into  the  mortal 
remains  of  the  patient's  companion  in  arms,  over  which  he  sat  up  in  bed  and 
gave  the  most  pathetic  but  maudlin  discourse.  Again  the  patient  may  expe- 
rience great  compunction,  and  mingle  the  touching  and  the  sad  with  the  ludi- 
crous. I  call  to  mind  one  who,  amid  his  vagaries,  stopped  to  thank  the  leeches 
which  had  been  applied  to  his  badly  sprained  ankle,  for  drawing  different  kinds 
of  liquor  from  him;  a  lively  fellow  was  taking  his  fill  of  champagne,  and  a 
sodden  chap  indulged  in  ale;  while  a  regular  soaker,  who  fell  off  motionless, 
got  dead  drunk  on  whiskey.  If  the  attack  be  not  arrested  by  sleep,  the  delu- 
sions are  no  longer  temporary,  but  continuous,  and  assume  sometimes  a  dis- 
tressing, and  at  other  times  a  violent  form.  Death  is  usual]}7  caused  by 
exhaustion ;  always  so  when  there  is  no  complication  of  organic  disease  or 
injury. 

A  layman  may  imagine  how  such  an  interloper  as  delirium  tremens  must 
interfere  with  satisfactory  surgical  practice,  but  no  one  but  a  surgeon  can 
appreciate  the  fact.  It  plays  havoc  with  all  his  calculations.  It  displaces  well 
adjusted  fractures,  reproduces  dislocations,  tears  open  wounds,  disturbs  dress- 
ings of  all  kinds,  removes  ligatures  and  sutures,  makes  simple  injuries  com- 
pound and  complex,  sets  up  irritative  abscesses  and  exudations,  and  so  opens 
the  door  for  erysipelas  and  pyaemia;  in  fact  it  is  a  fiend,  sitting  like  a  cormo- 
rant hard  by  the  surgeon's  efforts,  and  devouring  all  his  measures  for  good. 
It  might  be  thought  that  the  pain  produced  by  constant  movement  of  injured 
parts  would  be  a  reminder,  as  is  sometimes  the  case  in  traumatic  delirium,  and 
call  the  wandering  senses  to  order.  But  it  is  one  of  the  features  of  delirium 
tremens,  well  under  way,  that  the  patient  is  wholly  oblivious  to  pain  when 
injuries  arc  inflicted  upon  him  by  himself.  He  will  often  howl  with  fear  or 
agony  at  what  the  surgeon  does,  but  within  an  hour  may  be  grinding  the 
ends  of  his  broken  bones  together  as  though  they  were  mill  stones,  while  at 
the  same  lime  his  busy  brain  will  be  working  foolishness.  I'have  known 
two  men  with  broken  legs  to  get  up  and  have  a  fight.  It  is  not  at  all  uncom- 
mon to  see  a  man  with  a  broken  leg,  whose  habits  have  not  been  suspected, 
giving  the  first  signs  of  an  attack  of  delirium  by  getting  out  of  bed  with  his 
apparatus  on,  and  walking  about  the  room  or  ward.  These  facts  are  explana- 
tions of  the  seeming  conl  radiction,  that  a  man  in  delirium  tremens  is  an 
arrant  coward,  and  yet  will  cut  his  own  throal  or  shoot  himself  if  he  gets  a 
chance.  Sometimes  he  maims  himself  dreadfully  and  deliberately,  without 
any  idea  of  suicide.     I  know  of  one  who  coolly  cut  away  his  genital  organs, 


DIAGNOSIS    OF    DELIRIUM    TREMENS. 


399 


piece  by  piece,  and  fed  the  ducks  with  them.     Tain,  not  being  felt,  or  at  least 
regarded,  is  no  hindrance  to  the  act  of  self-wounding. 

I  shall  illustrate  delirium  tremens  as  to  its  special  clinical  features  in  sur- 
gical cases,  by  the  three  following  charts  (Figs.  34,  35,  36),  which  may  be 
called  typical. 


Fig.  34. 


o 

P 

a> 

3 

a 

p. 

6 

PS 

Temperature. 

Remarks. 

98         99             100           101 

—t-xJ.-L.     J_.l._l     I    !_.!_.!    1    1 

June 
21 

22 
23 

90 

80 

86 
"98~ 

96 

94 

89 
lif 

98 

22 
20 

M    ! 

DrHrium  very 
active  both 
nicrlit  and  day, 
requiring 
mechanical 
restraint. 

- 

Mild  delirium. 

(  Mild  delirium 
(  at  night. 

Quite  rational. 

E.   ! 

M. 

E. 

20 
"24" 

~22~ 
"24" 

28 

30 
"26" 

E. 

24 
25 
26 
27 

M. 

M. 
E. 
M. 

E.  j 

96 
80 
80 
80 

82 

24 
"22" 
~24~ 

21 
22~ 

M. 

X  i  i  i 

E.  ! 

28 
29 

98 

80" 

76" 

82 

80 

80 

22 

M. 

"e7 

M. 
E. 
M. 

24 

22 

24~ 

22~ 

22 

30 

July 
1 

2 

E. 

78 
80 
"80~ 

22 

22" 
20 

M. 

E. 

M. 

'    '    «■' 

i     r    ,    i 

i,-ii 

E. 

98           99           100           101 

Temperature  chart  of  S.  R.,  aged  38.  Delirium  tremens  following  fracture  of  femur.  Delirium 
appeared  the  first  night  after  the  patient's  admission  to  the  hospital.  The  treatment  consisted 
in  the  administration  of  bromide  of  potassium  and  chloral  hydrate.     Recovery. 

Diagnosis  of  Delirium  Tremens. — From  what  has  been  said,  it  will  be 
seen  that  the  diagnosis  of  delirium  tremens  is  generally  easy,  in  spite  of  the 
misrepresentations  which  are  made,  and  the  absolute  lies,  as  to  habits,  which 
are  too  apt  to  be  told,  both  by  the  patient  and  his  friends.  Sometimes  all  are 
deceived  in  the  matter,  and  the  attack  comes  on  as  a  surprise.  The  patient 
has  only  been  a  moderate  drinker,  and  if  the  additional  and  depressing  effects 
of  an  accident  had  not  occurred,  neither  himself  nor  his  friends  would  have 
even  thought  of  him  as  a  subject  for  the  disease.  Therefore,  it  is  but  justice  to 
say  that  patients'  statements,  denying  drinking  habits  to  any  harmful  extent, 
may  be  given  in  perfectly  good  faith.  The  ideas  of  people  differ  so  much  as 
to  what  is  harmful  in  this  matter,  that  it  is  important  for  the  surgeon  to  find 
oat  if  possible  what  are  really  the  facts  of  the  case,  both  a3  to  the  amount 
and  as  to  the  kind  of  liquor  used. 


400 


TRAUMATIC    DELIRIUM    AND    DELIRIUM    TREMENS. 

« 

Fie.  35. 


9 

a 

"5 

o 

'E. 

Temperature. 

Eemarks. 

98          99           100         101           102           103         104 

.    .    r    r     I     r  -i     ,         1    1    f_i         1   1    1  1         1     !.  LJ i   TT    ..                   1 

April     90 

30 
26 

M. 

Mild  delirium  at 
night. 

'               [ring  the  day. 
Passive  delirium  du- 
Active  delirium  at 

[night. 

Patient  quite  rational 
.  during  the  day.  Mild 
delirium  at  night. 

Active  delirium. 
•  Patient  strapped 
day  and  night. 

Delirium  continues 
.  violent ;  patient  has 
to  he  strapped  night 
and  day. 

[with  no  relapse. 
Patient  rational  now, 

11 

95 

X 

E. 

M. 

12 

13 
14 

100 

28 

98 
104 
100 
"95" 

Si! 

24 
30 
28 
26 

E. 
M. 

E. 
M. 

E. 
M.  i 

"E7! 

28 

N 

15 
16 

17 
IS 

SO 

92 

Te" 

85 
~90" 

28 
"26" 

i 

% 

26 

y 

M.  1 

28 

> 

e.  : 

"m7 

26 

82 
90 

24 

Till 

1      1      1       I 

,iii 

i  i.i  i 

1 1 1 1 

E.   l 

28 

M. 
E. 
M. 
E. 
M. 
E. 

"m7 

E. 
M. 
E. 
M. 
E. 

~m7 
E. 

80 

26 

19 

20 
21 
22 
23 

24 

84 
80 

1(10 
lo.; 

DS 
100 
f20" 

27 
26 
22 
24 
24 
"24 
24 

115 
116 
120 
120" 

26 

28 
26 
28 

"2fT 

1      ,      ,      1 

"" 

25 
2G 
27 
28 
29 
30 

110 
130 
112 
L15 

120 
L20 

US 
120 

98 

in; 

llo 
112 

26 
"28 
"26 
~28~ 

30 

30 

30 

32^ 

28 

30" 

35 

36 

M. 

— -~^ 

IT 

M. 

E~ 

M. 

E. 

M. 
~ET 

M. 
~E. 

M. 

E. 

M. 
-E. 

^-"-^ 

. — 

May 
1 

•  ■  i » 

98           99           100          101          102          103         104 

Temperature  chart  of  W.  II.,  aged  45,  a  moderate  drinker.  Delirium  tremens  following  com- 
pound fracture  of  leg  and  fracture  of  ribs.  The  treatment  consisted  in  the  hypodermic  use  of 
morphia  at  night,  with  the  internal  administration  of  large  doses  of  bromide  of  potassium  and 
chloral  hydrate.      Recovery. 


TREATMENT    OF    DELIRIUM    TREMENS. 


401 


The  peculiar  tremors  of  delirium  tremens  are  very  characteristic  ;  if  I  may 
go  express  it,  they  are  loose  and  free,  without  spasmodic  jerkings ;  somewhat 
jelly-like,  and  giving  a  general  idea  of  instability.  They  seem  to  say  "  prop 
me  up,  prop  me  up;" if  you  don't  prop  me  up,  I  shall  die." 


Fijr.  36. 


d 

a 

a 

o 

a 

a. 
P4 

Temperature. 

Bemark8. 

98          99           100           101         102           103 

June 

14 
15 

16 
17 
18 
19 
20 
21 
22 
23 

84 

80 
~8tT 

86 

86 

90 

98 
105 
120 
126 
124" 
108 
100 

94 

—~ 

18 
18 

M. 
E. 
M. 
E. 
M. 
E. 
M. 

1  Perfectly 
1  rational. 

J     [ p roach ing. 
Delirium  ap- 

1  Delirium 
r  very  active. 

20 

v 

20 
20 

■s 

22 

24~ 

24 

28 

30 

32 

30 

26 

24 

E. 
M. 

E.  ! 

<-- — T 

M. 

~eT 

Delirium 
'  moderating. 

-i  Delirium 
i  absent ;  pa- 
tient much 
i  prostrated ; 
action  of 
heart  rapid 
and  weak. 

M. 
E. 
M. 
E. 
M. 
"ET 

>> 

iiii 

>* 

90 
92 

84 
90 
86 

24 
23 
20 

20 

M. 

20 

X,  . 

*  1 1 1 

» i  i  ._ 

1  E- 

98           99           100           101         102          103 

Temperature  chart  of  A.  N.,  aged  50,  a  steady  drinker  but  not  an  habitual  drunkard.  Delirium 
tremens  following  fracture  of  the  patella.  During  the  stage  of  delirium  the  patient  was  treated 
with  morphia  hypodermically  (a  quarter  of  a  grain  every  six  hours),  and  chloral  (15  grains) 
and  bromide  of  potassium  (30  grains)  every  four  hours,  by  the  mouth.  The  diet  consisted  of 
liquid  and  concentrated  food  :  beef-tea  with  capsicum,  milk,  soup,  etc.  Mechanical  restraint 
was  employed  from  June  17  to  June  20.     Recovery. 

Treatment  of  Delirium  Tremens. — The  disease  being  one  of  depression, 
it  is  this  "  propping  up"  that  is  required  in  the  treatment.  Nourishment  and 
sleep  will  bring  most  cases  to  a  successful  issue.  Of  course  the  nourishment 
must  be  digested,  and  the  digestive  organs  may  not  at  first  be  ready  for  their 
work.  To  those  who  are  not  too  weak,  an  emetic  may  be  given  with  most 
excellent  effect.  One  of  the  best  is  mustard  and  water.  Then  the  bowels 
may  require  attention,  for  often  the  patient  has  been  very  neglectful  of  him- 
self in  this  respect.  An  enema,  a  large  one,  of  soap  and  water,  will  mostly 
accomplish  the  object.  This  plan  may  look  like  reducing  the  patient.  On 
the  contrary,  it  is  simply  aiding  to  bring  the  digestive  apparatus  into  a  recep- 
tive state.  There  is  no  use  in  cramming  down  what  will  not  be  assimilated, 
and  what  will  be  almost  certainly  rejected.  After  the  stomach  has  become 
somewhat  retentive,  we  may  begin  with  small  amounts  of  hot  and  well-spiced 
beef-tea,  or  soup,  repeated  at  short  intervals.  If  milk  can  be  taken,  so  much 
the  better.  As  to  medicines,  opium,  the  bromide  of  potassium,  chloral  hydrate, 
the  tincture  of  digitalis,  and  alcohol,  are  at  the  command  of  the  surgeon. 
vol.  i.— 26 


402  TRAUMATIC    DELIRIUM    AND    DELIRIUM    TREMENS. 

At  times  the  case  is  so  urgent  that  these  have  to  be  resorted  to  at  once,  in 
order  to  procure  sleep,  and  other  indications  may  be  met  afterwards.  It  is  in 
this  state  that  the  surgeon  most  frequently  finds  his  delirium-tremens  patients. 
Time  often  will  not  permit  him  to  take  risks.  Then  hypodermic  injections 
of  morphia  should  be  given  at  once.  In  cases  of  fracture,  the  limb  must  be 
so  guarded  and  bound  up  that  it  will  move  as  one  mass,  and  not  be  held  by 
extending  bands,  or  other  means,  to  fixed  places.  Soft  splints  padded  with 
cotton  should  be  applied,  and  then  the  part  may  be  bound  up  in  a  pillow.  A 
suspension  apparatus  may  also  be  useful.  One  has  to  be  regardless  of  the 
accurate  apposition  of  the  fragments ;  that  is  to  be  attended  to  after  quiet  and 
sense  have  been  restored.  Where  it  is  absolutely  necessary,  restraint  by 
strapping  the  uninjured  parts  to  the  bed  may  have  to  be  resorted  to.  Under 
all  circumstances  the  patient  must  be  most  carefully  watched,  for  in  some  way 
or  other  he  will  manage  to  disturb  his  dressings  or  to  injure  himself,  if  this 
be  not  done. 

When  sleep  comes  on,  everything  to  encourage  its  continuance  should  be  ob- 
served. When  the  patient  wakes  he  is  always  much  better,  and  often  perfectly 
sane.  Now  is  the  time  to  push  the  nourishment,  for  it  is  the  true  reliance  to 
bring  about  a  permanent  cure.  The  anodynes  and  stimulants  are  a  weak  prop, 
if  food  does  not  go  with  them.  They  may  be  gradually  withdrawn,  and  may 
be  again  resorted  to  in  full  measure  should  relapse  be  threatened.  It  is  not  my 
intention  in  this  article  to  discuss  the  relative  therapeutic  value  of  the  different 
remedies  for  delirium  tremens.  The  treatment  must  be  based  on  the  general 
principle  that  the  disease  is  one  of  depression.  Nourishment,  withdrawal 
from  exciting  surroundings,  and  sleep,  are  what  are  wanting.  Much  may  be 
done  to  ward  off  an  attack  if  the  surgeon  is  forewarned  as  to  habits.  Early 
measures  to  secure  rest  and  sleep,  under  these  circumstances,  will  often  be 
entirely  successful. 


ANESTHETICS  AND  ANESTHESIA. 

BY 

HENRY  M.  LYMAN,  A.M.,  M.D., 

PROFESSOK  OF  PHYSIOLOGY  AND  OF  DISEASES  OF  THE  NERVOUS  SYSTEM  IN  THE  RUSH  MEDICAL  COLLEGE, 

CHICAGO.      • 


The  term  Anesthesia,  derived  from  a  privative,  and  alae^ii  sensation,  is 
employed  to  signify  a  condition  of  the  nervous  system,  resulting  either  from 
disease  or  from  the  administration  of  certain  substances,  by  which  the  indi- 
vidual is  rendered  incapable  of  perceiving  external  impressions. 


History  of  Anaesthesia. 

From  the  earliest  ages  attempts  have  been  made  to  relieve  pain  by  the 
induction  of  insensibility.  Homer  records  the  use  of  cataplasms,  which 
doubtless  owed  a  portion  of  their  anodyne  efficacy  to  the  products  of  fermen- 
tation which  they  contained.  The  Egyptians  were  acquainted  with  the 
soothing  etfects  of  nepenthe,  a  drug  probably  identical  either  with  Indian 
hemp  or  with  opium.  Herodotus  refers  to  a  practice  among  the  Scythians 
of  inhaling  the  vapors  of  hemp  for  the  purpose  of  intoxication.  The  Chinese 
were  also  accustomed,  as  early  as  the  third  century,  to  produce  insensibility 
during  surgical  operations,  by  the  use  of  Indian  hemp.  There  is  a  tradition 
to  the  effect  that,  among  the  ancient  Assyrians,  the  pain  of  circumcision  was 
prevented  by  compression  of  the  veins  in  the  neck,  during  the  time  of  opera- 
tion. Pliny  and  Dioscorides  relate  that  the  Egyptians  possessed  a  species  of 
rock,  brought  from  Memphis,  which  they  were  accustomed  to  apply  in  the 
form  of  a  powder,  moistened  with  sour  wine,  to  painful  wounds.  This  was 
probably  a  primitive  method  of  producing  local  anaesthesia  with  carbonic 
acid  gas.  The  most  potent  anaesthetic  known  to  the  ancients  was  the  drug 
mandragora.  Its  infusion  in  wine  was  known  to  the  Greeks  by  the  name  of 
^morion.  Apuleius  states  that  half  an  ounce  of  this  preparation  would  render 
one  insensible  even  to  the  pain  of  an  amputation.  The  sleep  thus  produced 
might  continue  for  several  hours;  hence,  no  doubt,  the  origin  of  the  story  of 
the  sleep  of  Juliet,  as  recorded  by  Shakespeare.  The  Jewish  women  were 
accustomed  to  give  this  anesthetic  wine  to  the  victims  of  crucifixion ;  hence 
the  record  of  the  "wine  mingled  with  myrrh,"  in  the  gospel  of  St.  Mark. 

The  practice  of  inducing  annesthesia  by  inhalation,  may  be  traced  from  the 
Scythians  of  the  age  of  Herodotus,  through  the  middle  ages.  "While  Dante 
was  writing  the  Inferno,  Theodoric,  a  surgeon  of  Bologna,  taught  the  art  of 
producing  insensibility  by  inhalation  of  the  vapor  yielded  by  a  medicated 
Bponge  that  had  been  steeped  in  a  decoction  of  opium,  belladonna,  hyos- 
cyanms,  mandragora,  hemlock,  ivy,  and  lettuce.      It  is  probable  that  the 

(403) 


404  ANESTHETICS   AND   ANESTHESIA. 

anaesthetic  properties  of  ether  and  alcohol  were  known  to  the  alchemists. 
Giambattista  della  Porta,  in  a  volume  on  Natural  Magic,  described  the  pre- 
paration and  administration  of  certain  volatile  substances  which  were  to  be 
kept  hermetically  sealed  in  leaden  vessels,  to  preserve  their  virtues.  The 
effects  of  their  inhalation  appear  to  have  closely  resembled  those  of  ether. 
Albertus  Magnus  (A.  D.  1193-1280)  taught  the  art  of  distilling  fire-water 
(aqua  ardens)  from  red  wine  and  common  salt.  May  not  this  have  produced 
a  mixture  of  ether  and  alcohol  capable  of  producing  anaesthesia  by  inhalation? 
The  closing  years  of  the  last  century  were  marked  by  a  remarkable  apathy 
regarding  the  use  of  anaesthetics.  With  the  exception  of  opiates,  the  majority 
of  the  drugs  upon  which  the  ancients  relied  had  gone  out  of  fashion.  James 
Moore,  in  1784,  proposed  to  effect  anaesthesia  in  surgical  operations  by  com- 
pression of  the  principal  nerves  of  the  affected  limb.  John  Hunter  had 
observed  the  production  of  local  anaesthesia  by  refrigeration  of  the  tissues  of 
animals,  and  Baron  Larrey  had  remarked  the  same  thing  among  his  patients 
upon  the  icy  held  of  Eylau.  The  newly  discovered  gaseous  elements  had 
attracted  the  attention  of  chemists,  and  the  vapor  of  sulphuric  ether  had  been 
inhaled  by  Dr.  Pearson,  of  Birmingham,  as  early  as  1785,  but  without  prac- 
tical results.  In  the  year  1799  (April  9),  Humphry  Davy,  then  laboratory 
assistant  of  Dr.  Beddoes,  in  the  Pneumatic  Institution  at  Clifton,  near  Bristol, 
discovered  the  exhilarating  properties  of  nitrous  oxide  gas.  Shortly  after- 
wards, having  inhaled  the  gas  while  suffering  from  the  eruption  of  a  wisdom 
tooth,  he  observed  that  the  pain  was  relieved  while  under  the  influence  of 
the  gas.  He  recorded  his  experience,  with  the  following  comment :  "  As 
nitrous  oxide,  in  its  extensive  operation,  seems  capable  of  destroying  physical 
pain,  it  may  probably  be  used  with  advantage  in  surgical  operations  in  which 
no  great  effusion  of  blood  takes  place." 

Though  widely  circulated,  this  paragraph  seems  to  have  produced  no  prac- 
tical result  until  the  Hartford  dentist,  Horace  Wells,  turned  his  attention  to 
the  subject  in  the  year  1844.  During  this  long  period  of  time,  no  systematic 
research  had  been  undertaken  with  a  view  to  the  discovery  of  a  method  for 
the  production  of  artificial  anaesthesia.  The  anaesthetic  properties  of  sulphuric 
ether  were,  however,  being  gradually  ascertained  in  an  empirical  way.  In  the 
year  1785,  it  had  been  employed  by  Dr.  Pearson,  in  Birmingham,  as  an  inhala- 
tion for  the  relief  of  spasmodic  asthma.  Dr.  Warren,  of  Boston,  had  likewise 
used  it,  in  1805,  for  its  anodyne  effects  in  the  later  stages  of  consumption. 
In  the  year  1818,  Michael  Faraday  published  a  brief  notice  of  the  anaesthetic 
properties  of  ether  vapor,  which  he  considered  a  dangerous  substance.  Ex- 
perimental physiologists  also  became  acquainted  with  its  stupefying  effect 
upon  animals  ;  and,  in  the  year  1836,  Christison  recorded,  in  his  work  on  Poi- 
sons, the  case  of  a  young  man  who  had  been  rendered  completely  insensible 
by  the  vapor  of  ether.  Among  drug  clerks  and  reckless  young  people,  the 
practice  of  inhaling  the  vapor  of  ether  was  a  favorite  mode  of  dissipation  in 
certain  parts  of  the  world.  In  the  year  1839,  a  young  negro  was  thus  stupe- 
fied, to  the  great  alarm  of  his  companions,  in  the  village  of  Anderson,  South 
Carolina.  Tins  incident  served  to  encourage  Dr.  Long,  then  residing  in  Jef- 
ferson, ( Georgia,  to  administer  the  vapor  to  a  patient  who  was  accustomed  to 
1h''  practice  of  inhaling  ether.  He  was  thus  rendered  insensible,  and  a  tumor 
was  removed  without  pain,  March,  1K42.  Three  or  four  other  patients  were. 
anaesthetized  with  similar  success  during  the  years  1842  and  1843,  but  as  the 
doctor  resided  in  a  remote  and  isolated  portion  of  the  country,  and  as  he 
published  no  statement  of  his  experience,  his  discovery  remained  unknown 
to  the  scientific  world. 

During  the  month  of  December,  1844,  an  itinerant  lecturer  on  chemistry, 
named  Colton,  undertook  to  exhibit  the  exhilarating  properties  of  laughing- 


HISTORY   OF   ANESTHESIA.  405 

t 

gas  before  a  popular  audience,  in  the  city  of  Hartford,  Connecticut.  The 
dentist,  Horace  Wells,  who  was  present,  observed  that  the  person  to  whom 
the  gas  had  been  administered  seemed  quite  insensible  to  the  pain  of  the 
bruises  which  he  had  sustained  by  reason  of  a  fall  while  under  the  influence 
of  the  gas.  He  at  once  imagined  that  a  tooth  might  be  extracted  without 
pain  from  a  person  whose  sensibilities  were  thus  temporarily  obtunded.  The 
very  next  day  he  performed  the  experiment  upon  himself,  inhaling  a  quantity 
of  the  gas,  which  had  been  prepared  by  Dr.  Colton.  The  success  of  this 
attempt  was  complete,  and  in  a  few  weeks  he  had  in  like  manner  removed 
teeth  from  the  mouths  of  a  dozen  different  patients.  Visiting  Boston  for  the 
purpose  of  introducing  his  method  in  that  city,  he  undertook  to  extra* -i  a 
tooth  from  a  patient  to  whom  the  gas  had  been  administered  before  the  students 
of  the  Harvard  Medical  School.  The  experiment  was  unsatisfactory,  as  the 
patient  uttered  a  cry  at  the  moment  of  extraction,  though  he  afterwards 
asserted  that  he  had  felt  no  pain.  So  great  was  his  chagrin  at  this  failure, 
that  Dr.  Wells  ceased  to  interest  himself  in  the  subject  of  anaesthesia,  and  his 
death  occurred  not  long  afterwards  (Jan.  14,  1848).  Before  this  event,  how- 
ever, one  of  his  former  pupils,  a  young  dentist  in  the  city  of  Boston,  William 
T.  G.  Morton  by  name,  had  made  known  the  anaesthetic  properties  of  the 
vapor  of  sulphuric  ether.  At  the  suggestion  of  a  noted  chemist,  Dr.  Charles 
T.  Jackson,  lie  had  experimented  with  ether,  inhaling  its  vapor  until  insensi- 
bility had  been  induced.  This  event  occurred  during  the  evening  of  Septem- 
ber 30,  1846.  On  awaking  from  an  artificial  sleep  which  had  endured  for 
eight  minutes,  Dr.  Morton  resolved  to  administer  the  anaesthetic  vapor  to  the 
first  patient  who  would  submit  to  its  use.  A  man  named  Eben  Frost  pre- 
sently applied  for  relief  from  an  aching  tooth,  and  was  successfully  kept  under 
the  influence  of  ether  during  the  whole  time  of  the  extraction.  It  was  at 
once  perceived  that  this  discovery  might  find  a  wider  range  of  utility  than 
could  be  afforded  by  the  practice  of  dentistry,  and  on  the  16th  of  October, 

1846,  Morton  was  invited  to  etherize  a  patient  from  whom  Dr.  J.  C.  Warren 
was  about  to  remove  a  vascular  tumor  of  the  neck,  at  the  Massachusetts  General 
Hospital.  The  experiment  was  attended  with  such  a  degree  of  success  that 
it  was  again  and  again  repeated,  until  a  number  of  capital  operations  had 
been  thus  performed  with  the  most  satisfactory  results. 

Intelligence  of  the  great  discovery  reached  England,  December  17,  1846, 
and  was  speedily  diffused  throughout  the  civilized  world.  During  the  fol- 
lowing year,  the  celebrated  physiologist,  Flourens,  described  the  effects  of 
chloroform  upon  the  lower  animals.  A  medical  student  in  London,  Furnell 
by  name,  about  the  same  time  accidentally  discovered  its  anaesthetic  proper- 
ties by  inhalation  of  its  vapor,  and  at  his  suggestion  it  was  several  times 
employed  in  St,  Bartholomew's  Hospital  by  Sir  "William  Lawrence  and  Mr. 
Holmes  Coote.  In  the  mean  time  a  hint  regarding  this  substance  had  reached 
Dr.  J.  Y.  Simpson,  of  Edinburgh,  and  after  testing  the  drug  in  his  own  per- 
son he  administered  it  with  the  greatest  freedom.    "On  the  10th  of  November, 

1847,  he  published  the  details  of  not  less  than  fifty  cases  in  which  he  had 
used  chloroform  with  perfect  success.  The  agreeable  qualities  of  the  new 
anaesthetic  led  to  its  speedy  adoption  in  preference  to  ether.  The  occasional 
occurrence  of  death  from  its  effects  has  caused  much  debate  regarding  the 
comparative  dangers  from  the  use  of  different  anaesthetic  agents,  and  the 
superior  safety  of  ether  has  in  England  and  in  the  United  States  produced  a 
very  important  reaction  in  favor  of  the  original  agent  introduced  by  Morton. 
Germany  and  the  greater  portion  of  France  still. prefer  chloroform,  a  sub- 
stance which  by  its  energy,  its  concentration,  and  its  agreeable  effects,  will 
always  commend  itself  to  those  who  are  inclined  to  place  vigor  and  precision 
before  safety.     Many  other  substances  have  been  experimentally  tested  as 


406  ANAESTHETICS   AND   ANESTHESIA. 

anaesthetic  agents,  but  the  majority  of  them  are  either  too  dangerous  or  too 
costly  to  admit  of  general  use. 

Phenomena  of  Anesthesia. 

Certain  minor  peculiarities  characterize  the  anaesthetic  effects  produced  by 
inhalation  of  the  different  anaesthetic  gases  and  vapors.  The  principal  phe- 
nomena, however,  are  common  to  all.  A  description  of  the  symptoms  occa- 
sioned by  the  inhalation  of  the  vapor  of  ether  or  of  chloroform,  will  convey 
a  sufficiently  accurate  idea  of  the  manner  in  which  artificial  anaesthesia  ordi- 
narily supervenes. 

The  first  effect  of  the  inhalation  of  an  ethereal  vapor  is  a  local  excitement 
of  the  nervous  apparatus  of  the  respiratory  passages.  The  senses  of  taste 
and  smell,  and  the  naso-pha^ngeal  branches  of  the  fifth  pair  of  nerves,  are 
powerfully  excited.  The  activity  of  the  salivary  glands  is  aroused,  and  acts  of 
deglutition  are  stimulated.  Sometimes  a  disagreeable  tickling  is  experienced 
in  the  larynx,  and  the  patient  coughs.  A  sense  of  suffocation  may  be  expe- 
rienced, and  the  patient  assumes  an  attitude  of  resistance,  struggling  to  free 
himself  from  the  inhaler.  Animals,  confined  in  a  retentive  apparatus,  often 
endeavor  to  prevent  the  entrance  of  the  anaesthetic  vapor  by  restricting  their 
movements  of  respiration  within  the  narrowest  possible  limits. 

These  first  effects  of  local  contact  are  soon  succeeded  by  the  more  extensive 
results  of  general  saturation  of  the  tissues  with  the  stupefying  agent.  The 
vapor  rapidly  passes  into  the  blood,  and  is  conveyed  to  every  living  element 
of  the  body.  The  initial  effect  is  disturbance  of  function  ;  the  subsequent 
effect  is  paralysis  of  function.  Disturbance  usually  assumes  the  form  of  ex- 
altation ;  it  is  also  always  marked  by  perversion  of  the  normal  intensity  of 
physiological  sequences.  The  special  senses  give  evidence  of  this  agitation. 
There  is  a  humming  sound  in  the  ears,  and  subjective  impressions  of  light 
flash  in  varying  forms  across  the  visual  field.  The  pulsation  of  the  heart 
can  be  felt,  and  the  vermicular  movements  of  the  intestines  can  sometimes  be 
perceived.  The  arteries  throb,  the  brain  seethes,  waves  of  heat  flush  the  sur- 
face of  the  body,  perspiration  appears  upon  the  face,  and  may  become  gene- 
ral, the  pulse  rises,  respiration  is  accelerated,  the  pupils  contract,  the  eyes 
close,  reflex  irritability  is  exalted,  and  in  his  general  appearance  the  patient 
resembles  a  person  in  the  earlier  stages  of  alcoholic  intoxication.  To  this 
period  of  excitement  succeeds  the  stage  of  diminishing  function.  The  cuta- 
neous sensibility  grows  less,  the  temperature  falls,  the  pulse  recedes  towards 
the  normal  standard,  the  blood  pressure  diminishes,  the  respiratory  move- 
ments become  deep  and  full,  like  those  in  profound  sleep,  voluntary  move- 
ments cease,  consciousness  gradually  fails,  reflex  movements  are  abolished, 
and  the  patient  becomes  utterly  insensible.  If  the  act  of  inhalation  be  urged 
beyond  this  point,  syncope  may  occur,  and  a  cessation  of  respiration  and  cir- 
culation  may  terminate  the  life  of  the  patient. 

During  the  act  of  inhalation  the  eyes  are  generally  closed.  The  eyelids 
often  move  as  if  winking.  At  first,  the  pupils  are  variable  in  their  diameter. 
When  anaesthesia  is  fully  declared,  the  pupils  are  contracted;  but  if  the  con- 
dition of  stupefaction  is  carried  to  an  extreme,  dilatation  takes  place,  and 
persists  till  death.  During  the  period  of  complete  insensibility,  the  eyeballs 
arc  frequently  turned  upwards  and  inwards, sometimes  assuming  the  position 
of  con  jug:  i  ted  deviation.  General  sensibility  is  disturbed  at  a  very  early  stage 
of  the  anaesthetic  process.  After  the  brief  period  of  initial  exaltation,  cuta- 
neous sensibility  diminishes  at  a  rapid  rate.  This  diminution  is  first  mani- 
fested  u] ion    the  least   sensible  portions  of  the  surliice.     Sensibility  persists 


PHENOMENA    OF    ANESTHESIA.  407 

longest  upon  the  anterior  surfaces  of  the  trunk,  about  the  eyes,  at  the  tips  of 
the  lingers  and  toes,  and  especially  in  the  neighborhood  of  the  anus  and  the 
organs  of  generation.  The  initial  effects  of  inhalation  are  manifested  in  the 
brain  by  a  great  exaltation  of  the  powers  of  perception  and  reasoning.  Ideas 
are  quickened,  but,  with  a  diminution  of  the  powers  of  sensation,  the  sphere 
of  vivid  perception  is  correspondingly  narrowed.  Consciousness  remains  per- 
fect as  long  as  it  exists,  but  its  held  progressively  contracts  to  a  vanishing 
point,  around  which  seems  to  gather  an  atmosphere  of  half  formed  and  ever 
fainter  perceptions.  The  powers  of  attention,  memory,  reasoning,  judgment, 
and  volition,  can  be  exercised  with  perfect  precision  as  long  as  the  formation 
of  ideas  persists,  but  the  progressive  movement  towards  severance  of  the  brain 
from  all  contact  with  the  external  world  through  the  medium  of  the  senses, 
becomes  at  length  so  complete  that  consciousness  can  deal  only  with  ideas 
which  originate  within  the  brain  itself.  In  this  condition  the  patient  seems 
to  dream,  and  the  memory  of  these  dreams  may  be  preserved  after  awakening. 
Sometimes  all  avenues  of  communication  with  the  external  world  may  be 
closed  but  one — usually  the  sense  of  hearing — and  the  patient  experiences  a 
feeling  as  if  separated  from  his  body ;  as  if  occupying  the  position  of  an  im- 
passive spectator  of  the  scene  in  which  his  material  organization  forms  a  con- 
stituent part.  In  such  cases  volition  has  ceased ;  perception,  memory,  imagi- 
nation and  consciousness,  alone  remain.  But,  as  the  anaesthetic  process 
advances,  these  functions  also  lapse  into  the  potential  state,  and  the  patient 
passes  into  a  condition  of  vegetative  existence. 

The  effects  of  anaesthetics  upon  the  powers  of  volition  are  somewhat  variable. 
Children  and  adults  of  an  impressible  temperament  are  more  easily  overcome 
than  patients  of  a  vigorous,  intellectual  character.  By  an  effort  of  the  will, 
the  progress  of  anaesthesia  may  be  delayed,  and  a  mind  trained  in  habits  of 
introspection  and  analysis  will  retain  consciousness  longer  than  if  less  happily 
organized.  A  similar  phenomenon  is  often  remarked  during  the  progress 
towards  alcoholic  intoxication,  when  a  sudden  and  powerful  act  of  volition, 
exercised,  perhaps,  as  the  result  of  some  unexpected  stimulus  from  without, 
serves  to  restore  the  condition  of  sobriety.  By  such  effort,  and  even  without 
apparent  effort,  perfect  intelligence  may  often  be  maintained  for  a  consider- 
able period  after  the  loss  of  the  power  of  perceiving  painful  sensations.  The 
patient  may  be  conscious,  intelligent,  and  capable  of  conversation,  yet  almost 
wholly  insensible  to  pain;  and,  on  recovery,  quite  oblivious  of  the  passage  of 
time,  and  of  the  majority  of  the  events  that  have  transpired. 

During  the  initial  stage  of  anaesthesia,  the  power  of  muscular  movement  is 
usually  exaggerated.  Such  voluntary  movements  as  may  be  put  forth,  are 
performed  with  unwonted  vigor  and  celerity.  The  patient  may  raise  his 
hand  or  move  his  foot  without  willing  the  act,  yet  with  perfect  knowledge  of 
what  is  done.  The  involuntary  muscles  exhibit  the  general  disturbance  with 
the  greatest  uniformity.  The  heart  beats  more  rapidly,  and  sometimes  more 
violently ;  the  temples  throb ;  the  movements  of  respiration  are  accelerated. 
Sometimes  cough  will  be  excited,  the  patient  vomits,  the  bladder  and  the 
rectum  may  be  evacuated.  Convulsive  phenomena  sometimes  appear.  They 
may  be  limited  to  insignificant  fibrillary  twitchings  of  the  facial  muscles,  or 
the  patient  may  be  shaken  as  if  in  an  ague-fit.  "Epileptic  patients  may  be 
roused  by  the  anaesthetic  to  the  manifestation  of  a  complete  convulsion,  from 
which  they  will  pass  into  a  condition  of  the  most  profound  insensibility — a 
combination  of  coma  and  anaesthesia.  Sometimes  the  convulsive  movement 
assumes  the  tonic  form.  This  is  said  to  be  more  frequently  witnessed  as  a 
result  of  chloroform  than  of  ether.  An  arm  or  a  leg,  one  half  of  the  body, 
or  even  the  entire  frame,  may  become  perfectly  rigid  as  if  fixed  in  a  tetanic 


408  ANAESTHETICS   AND   ANAESTHESIA. 

spasm.     Such  conditions  indicate  a  profound  and  dangerous  implication  of 
the  most  important  nervous  centres. 

As  the  process  of  stupefaction  advances,  reflex  action  diminishes,  the  power 
of  voluntary  movement  ceases,  and  the  patient  enters  upon  a  condition  of 
perfect  repose,  in  which  the  only  movements  that  persist  are  those  which  sus- 
tain the  functions  of  respiration,  circulation,  and  unconscious  life.  By  careful 
administration  of  the  anaesthetic  this  condition  may  be  maintained  without 
danger  for  a  considerable  period  of  time. 

The  respiratory  movements  are  accelerated,  even  before  the  commencement 
of  inhalation,  when  the  patient  is  agitated  by  nervous  apprehensions.  Ether 
tends  to  quicken  respiration  during  the  early  and  middle  stages  of  inhalation, 
and  to  depress  its  rate  slightly  below  the  normal  when  the  stage  of  insensi- 
bility has  been  reached.  Chloroform  tranquillizes  the  initial  agitation  at  an 
earlier  stage  of  the  process,  and  produces  the  same  final  result  during  the 
period  of  unconsciousness.  Causes  dependent  upon  the  age,  sex,  temperament, 
and  previous  life  of  the  individual,  disturb  the  general  course  of  respiration 
to  such  a  degree  that  it  is  almost  impossible  to  include  all  cases  in  a  general 
description.  Sometimes  the  respiratory  movements  succeed  each  other  with 
the  utmost  irregularity,  and  may  even  be  suspended  altogether  for  a  consider- 
able time.  Such  patients  are  said  to  be  intolerant  of  the  anaesthetic,  and  are 
liable  to  pass  into  a  condition  bordering  on  the  convulsive  state.  In  certain 
cases,  the  patient,  though  quite  conscious  and  capable  of  intelligent  utterance, 
seems  to  have  forgotten  to  breathe.  From  this  condition  he  may  be  aroused 
by  the  voice  of  the  surgeon,  or  by  a  sudden  pressure  upon  the  thorax  or  abdo- 
men. During  the  stage  of  general  muscular  relaxation,  respiration  becomes 
deep  and  regular,  being  less  frequent  but  more  profound  than  during  the 
waking  state.  The  exhalation  of  carbonic  acid  gas  is  increased  during  the 
period  of  excitement,  and  it  is  diminished  during  the  period  of  tranquil 
anaesthesia. 

The  action  of  the  heart  corresponds  closely  with  the  conditions  of  respira- 
tion. During  the  occurrence  of  tetaniform  rigidity,  the  pulse  may  become 
almost  imperceptible.  When  respiration  is  slow  and  feeble,  the  heart  beats 
in  a  faint  and  sluggish  way.  Again,  it  may  suddenly  start  off  at  a  very  rapid 
rate,  only  to  sink  suddenly  into  a  condition  approaching  syncope.  Such  inor- 
dinate fluctuations  and  rapid  variations  should  excite  grave  apprehensions  for 
the  safety  of  the  patient.  In  the  normal  course  of  inhalation,  the  pulse  at 
first  is  small  and  frequent,  increasing  its  rate  as  respiration  becomes  accelerated, 
until  the  stage  of  muscular  resolution  is  approached,  when  it  begins  to  recede. 
With  the  approach  of  this  stage  the  arterial  coats  relax,  and  the  pulse  grows 
soft.  When  complete  unconsciousness  supervenes,  the  volume  of  the  pulse  is 
considerably  enlarged,  and  its  rate  may  tall  below  the  normal  standard.  As 
the  pulse  falls,  the  general  circulation  improves.  Turgid  veins  subside  ;  the 
cutaneous  vessels  resume  their  normal  calibre.  The  face  may  even  become 
pale,  and  the  mucous  surfaces  exchange  their  lively  color  for  a  fainter  tinge. 
Extreme  pallor,  or  a  dusky  hue,  should  be  viewed  with  alarm. 

The  temperature  of  the  body  is  generally  diminished  during  the  time  of 
anaesthesia.  At  first,  the  temperature  of  the  surface  is  elevated  by  reason  of 
the  increased  afflux  of  blood;  but  as  inhalation  progresses  the  liberation  of 
heat  diminishes,  and  the  temperature  of  the  body  exhibits  a  considerable  fall. 
This  becomes  more  notable  when  the  more  energetic  a naesthetic  substances 
are  employed. 

The  function  of  secretion  is  at  first  augmented,  and  finally  diminished  by 
the  action  of  anaesthetics.  The  degree  01  augmentation  depends  considerably 
upon  the  character  of  the  anaesthetic  that  is  employed. 


PHYSIOLOGY   OF   ANAESTHESIA.  409 

The  time  during  which  anaesthesia  may  persist  after  the  cessation  of 
inhalation,  is  quite  variable,  being  dependent  upon  the  volatility  of  the 
agent.  It  is  visually  three  or  four  minutes  after  the  use  of  ether,  and  a 
little  longer  after  that  of  chloroform.  Recovery  is  almost  immediate  after 
the  employment  of  nitrous  oxide  or  ethyl  bromide.  When  the  patient  has 
been  made  insensible,  the  condition  of  anaesthesia  may  be  indefinitely  main- 
tained by  the  continuous  administration  of  relatively  small  quantities  of  the 
drug.  A  condition  in  which  the  patient  continues  to  moan  and  to  cry,  per- 
haps even  resuming  a  feeble  struggle  with  the  attendants,  is  an  evidence  That 
the  anaesthetic  is  either  not  properly  inhaled,  or  that  the  individual  is  in  a 
situation  not  wholly  free  from  danger.  Careful  administration  will  generally 
overcome  the  difficulty,  but  certain  patients  are  especially  refractory.  Drunk- 
ards, by  reason  of  long  established  tolerance  of  the  anaesthetic  effects  of  alcohol, 
require  large  and  sometimes  dangerous  quantities  of  ordinary  anaesthetics  to 
effect  resolution  and  insensibility.  Mental  agitation  may  produce  a  temporary 
tolerance.  Operations  about  the  anus  and  genitalia  generally  require  an 
unusual  quantity  of  anaesthetic  vapor  for  the  production  of  complete  anaes- 
thesia. 

The  phenomena  of  recovery  ordinarily  consist  in  a  regular  inversion  of  the 
manifestations  which  have  marked  the  process  of  induction.  If  the  patient 
has  been  previously  exhausted  by  any  cause,  the  period  of  recovery  may  be 
greatly  prolonged,  and  symptoms  of  prostration  may  appear.  After  a  long 
and  difficult  operation,  it  may  be  difficult  to  distinguish  between  the  effects 
of  shock  and  those  of  the  anaesthetic.  Brief  operations,  on  the  contrary, 
seem  to  produce  less  depression  when  the  element  of  pain  is  abolished. 


Physiology  of  Anesthesia. 

The  action  of  anaesthetic  substances  is  exerted  through  the  blood  upon  the 
nervous  system.  They  operate  by  contact,  rather  than  by  chemical  union 
or  decomposition.  This  mode  of  action  is  exhibited  by  many  of  them  in 
connection  with  non-vital  processes  of  a  chemical  character.  A  taper  will 
he  extinguished  in  a  jar  containing  one  part  of  carbonic  anhydride  mixed 
with  seven  parts  of  oxygen,  just  as  readily  as  in  an  atmosphere  deprived  of 
oxygen.  The  anhydride  effects  an  arrest  of  the  process  of  oxidation  by  its 
mere  presence,  without  in  any  way  taking  the  place  of  either  oxygen  or 
oxidizable  substance.  In  like  manner,  the  luminous  oxidation  of  hydrogen 
phosphide  may  be  arrested  by  the  presence  of  a  very  small  quantity  of  "the 
vapor  of  ether,  or  turpentine,  or  naphtha.  The  luminous  glow  that  is  visible 
around  a  stick  of  phosphorus  in  a  darkened  room,  will  at  once  disappear  if  a 
drop  of  ether  or  chloroform  be  introduced  into  the  container.  As  the  ethe- 
real vapor  is  dissipated  by  evaporation,  oxidation  begins  again,  and  the  phos- 
phorus glows  once  more  as  perfectly  as  at  first.  Upon  the  more  complicated 
processes  of  vegetable  life,  these  substances  exert  a  similar  inhibitory  influence. 
The  addition  of  ether  to  an  infusion  containing  yeast,  at  once  arrests  the  pro- 
cess of  fermentation.  On  removal  of  the  anaesthetic,  by  evaporation  or  by 
filtration,  the  activity  of  the  yeast  fungus  is  renewed,  and  fermentation  is 
again  resumed.  If  an  aquatic  plant  be  placed  in  a  watery  solution  of  ether 
or  chloroform,  its  absorption  of  carbonic  anhydride  and  its  exhalation  of 
oxygen  cease.  The  plant  does  not  die  ;  it  merely  sleeps.  On  replacing  it  in 
pure  water,  its  natural  respiration  is  immediately  resumed.  The  germination 
of  seeds  may  also  in  a  similar  manner  be  arrested  by  surrounding  them  with 
an  anaesthetic  atmosphere.  The  irritability  of  the  protoplasm  in  the  cells  at 
the  base  of  the  petiole,  in  the  leaf  of  the  sensitive  plant,  is  in  like  manner 


410  ANAESTHETICS   AND   ANESTHESIA. 

inhibited  by  anaesthetic  vapors.  A  vigorous  specimen  of  this  species,  placed 
for  half  an  hour  under  a  bell-glass  with  a  sponge  saturated  with  ether,  will 
no  longer  exhibit  any  irritability.  Its  healthy  appearance  remains  unchanged, 
but  it  no  longer  absorbs  carbonic  anhydride,  and  its  leaflets  will  not  shrink 
when  touched.  Restoration  of  the  plant  to  a  pure  atmosphere  is  soon  fol- 
lowed by  complete  recovery  of  all  its  natural  functions. 

Each  one  of  these  experiments  illustrates  the  tendency  to  inhibition  of  cer- 
tain molecular  movements  in  the  presence  of  an  anaesthetic  substance.  All 
molecular  movement  is  not  thus  arrested.  Alcoholic  fermentation  ceases  in  a 
solution  of  ether,  which  still  permits  the  transformation  of  cane-sugar  into 
grape-sugar.  It  is  at  present  impossible  to  describe  the  essential  nature  of 
the  inhibitory  process.  The  only  thing  beyond  dispute  is  the  fact  that  anaes- 
thetic substances  tend  to  restrict  the  ordinary  freedom  of  chemical  exchanges 
in  living  matter.  In  the  animal  body,  while  all  parts  are  thus  modified  by 
the  anaesthetic,  certain  tissues  are  more  than  others  affected  by  its  presence. 
To  this  fact  is  due  the  progressive  character  of  artificial  anaesthesia.  The 
more  highly  differentiated  the  tissues  of  an  animal,  the  more  evidently  suc- 
cessive and  complex  the  phenomena  of  anaesthesia.  Consequently  it  is  in  the 
higher  animals,  with  an  elaborate  nervous  apparatus,  that  these  phenomena 
are  most  conspicuous. 

The  action  of  anesthetic  vapors  and  liquids  is  exerted  through  the  medium 
of  the  circulating  fluids  of  the  body  upon  the  cellular  units  of  which  it  is 
composed.  Introduced  into  the  blood  by  passage  through  the  walls  of  the 
pulmonary  air-cells,  absorbed  by  the  surfaces  of  the  alimentary  canal,  or  con- 
veyed directly  into  the  current  of  the  blood  by  intra-venous  injection,  it  is 
only  when  the  nervous  elements  have  been  reached  that  the  anaesthetic  process 
begins.  Primarily  local  in  its  action,  the  effect  of  the  anaesthetic  becomes 
generalized  when  the  central  nervous  organs  are  invaded.  Numerous  experi- 
ments have  thus  shown  that  the  local  action  of  chloroform  upon  the  substance 
of  the  spinal  cord  is  sufficient  to  abolish  peripheral  sensation  and  muscular 
movements,  even  though  the  peripheral  organs  have  been  sheltered  from  its 
action.  In  like  manner,  the  functions  of  the  brain  having  been  abolished,  all 
those  peripheral  functions  which  depend  upon  the  integrity  of  the  cerebrum 
are,  for  the  time  being,  incapable  of  performance.  When  freely  circulated 
through  all  parts  of  the  body,  the  anaesthetic  produces  local  effects  throughout 
the  whole  mass  of  the  body,  but  the  consequences  of  its  action  upon  the 
principal  nervous  centres  are  the  most  conspicuous  of  the  resulting  phe- 
nomena. 

The  condition  of  artificial  anaesthesia  presents  many  points  of  resemblance 
to  natural  sleep,  but  there  are  also  certain  important  points  of  difference.  The 
advent  of  normal  sleep  is  heralded  by  a  gradual  failure  of  the  special  senses. 
The  eyes  close,  general  sensibility  fails,  and,  finally,  the  sense  of  hearing  is 
abolished.  In  the  locomotive  apparatus,  the  voluntary  muscles  of  the  limbs 
are  the  first  to  yield  ;  then  follow  the  muscles  of  the  trunk.  The  power  of 
reflex  movement  is  not  abolished.  Respiration  and  circulation  continue, 
though  with  a  slightly  diminished  rate.  As  sleep  invades  the  brain,  percep- 
tion of  the  external  world  is  gradually  diminished  by  the  failure  of  the 
external  senses.  But  this  arrest  of  communication  does  not  at  once  prevent 
the  development  of  ideas  within  the  brain.  Certain  groups  of  cortical  cells 
may  remain  active  after  the  establishment  of  sleep  in  certain  other  groups. 
1  >eprived  of  that  guidance  which  is  derived  from  the  impressions  of  sense,  the 
attention  of  tin ■  waking  portions  of  the  brain  is  attracted  to  such  impressions 
of  internal  origin  as  may  arise  in  the  territories  of  the  pneumogastric  and 
sympathetic  nerves.  Hence  a  succession  of  erratic  ideas,  attended  with 
varying  degrees  of  consciousness,  dependent  upon  the  degree  of  uniformity  in 


PHYSIOLOGY   OF   ANESTHESIA.  411 

the  condition  of  the  cortical  portion  of  the  brain.  Or  disturbing  causes  may 
be  originated  in  the  cerebral  centres  themselves.  Groups  of  cells  which  have 
acquired  an  excessive  or  morbid  irritability,  may  still  continue  to  perform  a 
certain  amount  of  functional  Work  as  a  consequence  of  previous  impressions 
that  have  not  yet  been  effaced,  and  this  work  will  produce  results  in  the 
field  of  consciousness.  But,  through  lack  of  a  simultaneous  production  in 
consciousness,  of  that  vast  complex  of  associated  perceptions  and  conceptions 
which  is  occasioned  by  the  coordinated  activity  of  all  parts  of  the  brain 
during  the  waking  state,  this  isolated  cell-work  excites  only  imperfect  trains 
of  thought,  which  must  necessarily  progress  after  a  very  imperfectly  ordered 
fashion.  Such  processes  constitute  what  is  called  a  dream.  When  the  special 
function  of  the  cortical  cells  is  rapidly,  uniformly,  and  completely  arrested, 
sleep  is  profound  and  dreamless.  The  development  of  this  condition  is 
accompanied  by  a  comparatively  anemic  condition  of  the  cerebral  substance. 
This  comparative  anaemia  is  the  result,  rather  than  the  cause,  of  sleep.  It  is 
effected  by  the  intervention  of  the  nerves  which  regulate  the  supply  of  blood 
for  every  organ,  in  strict  accordance  with  the  degree  of  its  functional  activity. 

Quite  unlike  the  advent  of  natural  sleep  is  the  stormy  introduction  to  the 
sleep  of  artificial  anesthesia.  This  is  due  to  the  fact  that  the  anesthetic 
sleep  is  produced  by  the  action  of  a  foreign  substance  of  a  paralyzing  nature, 
to  which  the  tissues  are  wholly  unadjusted.  The  initial  effects  of  contact 
with  such  a  substance,  are  contraction  of  irritable  protoplasm,  liberation  of 
motion,  phenomena  of  excitement.  This  produces  an  increased  circulation  of 
blood,  and  all  the  functions  of  the  nervous  system  are  momentarily  exalted  by 
the  combined  action  of  increased  blood-supply  and  local  irritation  of  nervous 
matter.  But  the  conspicuous  and  characteristic  phenomena  of  anesthesia  are 
caused  by  the  paralyzing  energy  of  the  anesthetic.  At  first  the  vascular 
walls  contract,  as  a  consequence  of  their  local  irritation  by  the  medicated 
blood.  But,  almost  immediately,  they  begin  to  relax  under  the  paralyzing 
influence  of  the  drug,  and  an  increased  supply  of  blood  reaches  the  muscular 
and  nervous  substance  of  the  heart.  This  organ  contracts  more  vigorously, 
and  propels  through  the  dilating  bloodvessels  a  larger  amount  of  blood,  to 
stimulate  the  brain,  the  spinal  cord,  and  every  portion  of  the  body.  A  gene- 
ral though  temporary  increase  of  function  iS  the  result.  Muscular  movement 
and  reflex  action  are  exaggerated.  The  sensory  apparatus  is  in  like  manner 
rendered  more  efficient.  Painful  sensations,  may  thus  be  briefly  intensified 
by  the  means  that  are  employed  for  their  abolition.  But  this  stage  of  ex- 
citement is  soon  passed.  Transported  by  the  blood,  the  anesthetic  soon  per- 
vades the  higher  nervous  ganglia,  and  depresses  their  activity.  The  action 
of  the  heart  is  thus  retarded,  and  the  pulse  recedes.  In  like  manner  the 
movements  of  respiration  are  again  brought  down  to  the  normal  rate,  or  even 
belt  >w  it.  The  circle  of  the  intellectual  functions  is  progressively  narrowed 
by  the  progressive  paralysis  of  the  cortical  cells,  and  the  connection  of  ideas 
is  disturbed  by  the  increasing  disconnection  of  the  centres  in  which  they 
arise.  Complete  paralysis  of  these  organs  is  followed  by  loss  of  consciousness 
and  anesthesia.  If,  now,  an  equilibrium  be  established  between  the 'intro- 
duction and  the  elimination  of  the  stupefying  vapor,  the  anesthetic  process 
may  be  continuously  sustained.  But  if  its  introduction  be  urged  beyond  the 
power  of  the  tissues  to  free  themselves,  they  become  supersaturated,  and 
systemic  death  is  the  final  result. 

Reasoning  from  analogy,  it  has  been  suggested  that  anesthetic  substances 
modify  nervous  tissue  by  a  sort  of  coagulation  of  its  protoplasm.  But  coagu- 
lation is  incompatible  with  life.  Keeping  in  mind  the  tact  that  the  effect  of 
anesthetic  substances  is  temporary,  it  seems  more  probable  that  they  operate 
by  inhibition  of  those  chemical  processes  which  are  associated  with  the  libe- 


412  ANESTHETICS   AND   ANESTHESIA. 

ration  and  diffusion  of  motion  throughout  the  system.  Among  the  proto- 
plasmic molecules,  the  substance  acts  the  part  of  a  screen, like  a  cloud  between 
the  sun  and  the  earth,  hindering  the  energies  of  one  from  acting  upon  the 
susceptible  matter  of  the  other.  Too  frequent  repetition  of  this  action,  how- 
ever, eventuates  in  the  production  of  certain  permanent  modifications  in  the 
constitution  of  living  matter.  These  are  best  illustrated  by  reference  to  the 
permanent  alterations  of  nervous  tissue  which  are  produced  by  the  immode- 
rate use  of  alcoholic  anaesthetics. 


Mode  of  Administering  Anesthetics. 

The  patient  should  occupy  a  recumbent  position  in  order  to  facilitate  the 
circulation  of  blood  between  the  heart  and  the  brain.  Clothing  should  be 
adjusted  in  a  way  to  permit  the  freest  respiratory  movements.  The  anaes- 
thetic substance  may  ordinarily  be  inhaled  as  it  evaporates  from  a  napkin 
placed  over  the  mouth  and  nostrils.  Innumerable  forms  of  more  or  less  com- 
plicated apparatus  have  been  contrived  for  the  administration  of  graduated 
quantities  of  anaesthetic  vapor ;  but  the  majority  of  these  inhalers  are  dirty, 
cumbrous,  disappointing,  and  unsafe.  For  ordinary  use  nothing  has  yet  been 
found  better  than  the  simple  napkin  or  its  equivalent.  For  the  administra- 
tion of  nitrous  oxide  gas,  a  special  form  of  inhaling  apparatus  is  necessary, 
since  it  is  important  that  all  air  be  excluded  during  the  act  of  inhalation. 
(Figs.  37,  38.)  A  very  ingenious  and  useful  inhaler  has  been  contrived  by 
Mr.  Clover,  an  English  surgeon  of  large  experience  with  anaesthetics,  for  either 
the  successive  or  the  simultaneous  inhalation  of  nitrous  oxide  gas  and  ether 
vapor.  (Fig.  39.)  With  these  exceptions,  the  simplest  means  of  introducing 
the  anaesthetic  vapor  into  the  lungs  are  always  the  best.  During  the  whole 
time  of  inhalation,  the  condition  of  the  patient  should  be  continually  observed 
by  an  experienced  physician,  and  the  earliest  symptoms  of  danger  should  be 
immediately  noted  and  opposed  by  vigorous  treatment.1 


Accidents  of  Anesthesia. 

In  certain  rare  cases,  death  may  occur  suddenly  during  the  act  of  tranquil 
inhalation.  The  movements  of  the  heart  and  of  the  respiratory  organs  seem 
to  be  almost  instantaneously  arrested;  this  accident  seldom  occurs  unless  the 
patient  has  been  greatly  enfeebled  by  previous  disease  or  by  hemorrhage. 
Death  by  asphyxia  may  occur  during  the  act  of  inhalation.  This  accident 
might  be  occasioned  by  the  use  of  a  badly-adjusted  inhaling  apparatus,  or  by 
suffocation  with  numerous  wet  napkins  crowded  upon  the  face;  but  this  must 
lie  ;iu  exceedingly  unusual  event.  It  is  when  the  trachea  has  been  mechani- 
cally obstructed  by  tin*  entrance  of  blood  from  a  wound,  or  by  the  intrusion 
of  fragments  vomited  from  the  stomach,  that  asphyxia  is  beyond  doubt  the 
cause  of  death.  Asphyxia  may  occasionally  be  produced  by  the  induction  of 
tonic  convulsion  of  the  respiratory  muscles,  as  a  reflex  consequenceof  the 
local  irritant  action  of  chloroform  vapor  when  brought  in  contact  with  the 
laryngeal  mucous  surfaces.  Ordinarily,  however,  the  consequences  of  such 
local  irritation  are  confined  to  the  production  of  a  tumultuous  cough.  More 
frequently  the  intervention  of  danger  manifests  itself  by  prolongation  of  the 
Btage  of  excitement.     The  muscles  may  finally  pass  into  a  condition  of  rigid- 

1  [Further  remarks  upon  the  administration  of  special  anaesthetics  will  be  found  under  the 
head  of  the  different  agents  employed.     Bee  pp.  424  et  seq.~\ 


ACCIDENTS    OF    ANESTHESIA. 
Fig.  37. 


413 


Codman  and  Shurtleff 's  inhaler  for  nitrous  oxide  gas.     A,  metallic  hood  ;  B,  flexible  rubber  hood ;  C,  exhaling 
valve  ;  1),  two-way  stop-cock  ;  E,  sliding-joint ;  J,  inhaling  valve. 


Fie.  38 


The  same  apparatus  adapted  for  the  inhalation  of  ether.     F,  ether  reservoir. 


Fie.  39. 


Rc= 


-lover's  apparatus  for  inhalation  of  nitrous  oxide  gas  and  ether.     E,  ether  reservoir :  F.  fare-piece  j   G,  caoutchouc 
bag  for  mixture  of  vapors  ;  R  Kl,  nitrous  oxide  reservoir ;  Re,  regulator. 


414  ANESTHETICS   AND   ANAESTHESIA. 

ity,  during  which  the  pulse  suddenly  disappears,  respiration  ceases,  and  death 
occurs.  Death  in  all  such  cases,  and  they  form  the  vast  majority  of  the 
examples  of  death  during  the  anaesthetic  process,  is  the  direct  result  of  the 
toxic  effects  of  the  drug  upon  the  nervous  centres  which  preside  over  the  acts 
of  circulation  and  respiration.  It  is,  therefore,  impossible  to  employ  any 
anaesthetic  agent  without,  in  some  small  degree,  at  least,  approaching  the  con- 
fines of  danger.  All  diseases  which  diminish  the  energy  of  the  heart  and  of 
the  lungs,  tend  to  increase  the  dangers  of  anaesthesia.  Hemorrhage,  intem- 
perance^ cold,  hunger,  want,  misery,  mental  anxiety,  loss  of  sleep,  fatigue,  are 
all  causes  of  danger,  because  they  serve  to  depress  the  vital  energies.  Since 
suffocation  by  the  passage  of  food  into  the  trachea  has  occurred  during  the 
ace  of  vomiting  excited  by  the  anaesthetic,  it  is  advisable  to  administer  the 
vapor  at  a  time  when  the  stomach  is  probably  empty. 

The  rate  of  inhalation  may  become  a  source  of  danger.  Hasty  saturation 
of  the  tissues  with  a  powerful  anaesthetic  may  cause  speedy  death.  The 
primary  stage  of  anaesthesia  is  a  period  of  excitement,  during  which  it  is  not 
impossible  that  fatal  syncope  may  result  from  over-stimulation  of  the  cardiac 
inhibitory  apparatus  before  the  fully  toxic  action  of  the  drug  has  been  dis- 
played. Convulsions  may  thus  be  aroused,  and  may  produce  death  by  arrest 
of  respiration,  or  they  may  be  the  forerunners  of  fatal  syncope.  Sudden 
excitement  of  the  reflex  apparatus,  by  incision  of  the  skin  before  complete 
abolition  of  sensibility,  may  in  like  manner  become  a  cause  of  death.  It  is 
for  this  reason  always  best  to  produce  complete  insensibility  before  the  com- 
mencement of  an  operation,  even  though  a  certain  slight  risk  of  over-satura- 
tion of  the  tissues  be  thus  incurred. 

As  a  general  fact,  children  are  remarkably  tolerant  of  anaesthesia.  The 
rapid  rate  of  circulation  and  respiration,  and  the  larger  relative  surfaces  of 
their  bodies,  provide  for  a  speedy  elimination  of  the  anaesthetic  substance, 
so  that  cumulative  effects  are  almost  out  of  the  question.  Aged  jiersons,  also, 
have  been  claimed  as  more  than  ordinarily  favorable  subjects  for  artificial 
anaesthesia.  Few  old  people,  however,  become  the  objects  of  such  experiment, 
and  the  fatality  among  them  must  therefore  seem  to  be  less  than  among  the 
middle-aged  who  form  the  mass  of  patients.  To  such  elderly  patients,  anaes- 
thetics should  be  administered  with  more  than  ordinary  care,  for  with  them 
the  phenomena  of  anaesthesia  are  liable  to  assume  an  adynamic  character. 
Women  resemble  children  in  the  rapidity  with  which  they  yield  to  inhalation. 
It  has  been  thought  that  they  are  less  liable  than  men  to  the  accident  of 
syncope  during  anaesthesia.  At  the  menstrual  epoch  they  are  more  than 
usually  liable  to  nervous  excitement  and  to  hallucinations,  but  are  otherwise 
not  excessively  exposed  to-  danger.  During  the  period  of  pregnancy,  aside 
froi  ii  the  risk  of  injury  through  violent  muscular  efforts  in  the  stage  of 
excitement,  there  seems  to  be  no  unusual  risk  from  artificial  anaesthesia. 
The  act  of  parturition  seems  to  confer  almost  absolute  immunity  from  danger 
through  anaesthetic  inhalation.  Peculiarities  of  temperament  and  constitution 
appear  to  exereise  no  appreciable  effect  upon  the  course  of  anaesthesia.  A 
predisposition  to  syncope  does  indeed  furnish  a  contra-indication  to  the  use  of 
anaesthetics. 

Various  diseases  of  the  brain  and  spinal  cord,  especially  such  as  encroach 
upon  the.  medulla  oblongata  and  its  neighborhood,  increase  the  danger  of 
accident.  Epileptics  are  very  liable  to  convulsion  during  the  stage  of  excite- 
ment, but  the  immediately  subsequent  stage  of  resolution  is  sufficiently  favor- 
able to  warrant  the  administration  of  anaesthetics  to  such  patients.  The 
same  thing  is  true  of  hystero-epilepsy.  Alcoholic  intoxication  and  delirium 
tremens  prohibit  inhalation,  because  of  the  existing  tendency  to  death  from 
exhaustion  and  syncope.     Surgical  shock,  for  the  same  reason,  constitutes  a 


ACCIDENTS   OF   ANESTHESIA.  415 

condition  unfavorable  to  the  employment  of  anaesthetics.  Gunshot  wounds 
seem  to  form  an  exception  to  this  rule,  probably  because  of  the  great  nervous 
exaltation  which  usually  precedes  their  infliction.  All  forms  of  "pulmonary 
and  intrathoracic  disease  add  to  the  risks  of  artificial  anaesthesia,  not  through 
any  increased  liability  to  asphyxia,  but  by  reason  of  the  greater  probability 
of  the  occurrence  of  syncope.  For  the  same  reason,  organic  diseases  of  the 
heart  or  the  larger  bloodvessels,  overloading  of  the  heart  with  fat,  and  fatty 
degeneration  of  its  muscular  structure,  should  preclude  the  use  of  anaesthetics. 
A  slow,  irregular,  and  feeble  pulse,  associated  with  precordial  pain,  difficult 
respiration,  general  lassitude,  and  evidences  of  degeneration  in  tissues  accessi- 
ble to  observation,  should  excite  suspicion  of  this  form  of  morbid  change. 
The  violent  palpitations  of  anaemia  should  exclude  the  more  potent  anaes- 
thetics. 

A  condition  of  excitement  and  terror,  preceding  the  act  of  inhalation,  may 
increase  the  risks  to  which  the  individual  is  subjected.  A  certain  amount  of 
encouragement  and  reassurance  of  the  timid  patient,  together  with  repeated 
stimulant  doses  of  alcohol,  should  always  precede  the  exhibition  of  the  anaes- 
thetic in  such  neurasthenic  cases. 

The  risk  of  accident  varies  greatly  in  accordance  with  the  nature  of  the 
substance  selected  for  the  production  of  insensibility.  It  should,  however, 
always  be  remembered  that  no  anaesthetic  agent  is  absolutely  free  from  risk. 
Every  patient  should,  therefore,  be  made  an  object  of  special  study  before  the 
commencement  of  inhalation,  and  all  possible  contra-indications  should  be 
fully  considered. 

Treatment  of  the  Accidents  of  Anesthesia. — Irritation  of  the  respira- 
tory passages  caused  by  inhalation  of  anaesthetic  vapor,  soon  subsides  after  the 
occurrence  of  complete  anaesthesia,  or  after  removal  of  the  cause.  If  it  per- 
sists, the  purity  of  the  substance  should  be  determined.  Vomiting  not  un- 
frequently  occurs,  especially  if  food  has  been  recently  taken.  It  is,  therefore, 
expedient  to  defer  inhalation  for  three  or  four  hours  after  a  meal.  The  sen- 
sation of  suffocation  which  often  oppresses  the  patient  during  the  earlier 
stages  of  inhalation,  maybe  relieved  by  larger  dilution  of  the  vapor  with  air. 
If  the  anaesthetic  is  given  upon  a  napkin,  the  cloth  should  be  raised  from  the 
face  for  a  few  seconds.  Tolerance  of  the  vapor  will  soon  be  established,  and 
inhalation  may  then  be  rapidly  conducted. 

The  principal  dangers  during  inhalation  are  the  arrest  of  respiration,  and 
the  cessation  of  cardiac  movement.  As  a  general  thing,  if  respiration  can  be 
sustained  the  heart  will  continue  to  act.  It  is,  therefore,  important,  whenever 
alarming  symptoms  appear,  to  guard  the  breathing — even  to  the  extent  of 
producing  artificial  respiration.  This  may  be  effected,  preferably,  by  the 
methods  of  Sylvester  or  of  Howard.  The  tongue  may  be  drawn  forward, 
not  because  the  glottis  can  be  thus  opened,  but  for  the  sake  of  the  reflex 
actions  of  respiration  which  may  be  excited.  Faradaic  stimulation  of  the 
thoracic  surface  may  also  be  attempted.  A  powerful  current  should,  how- 
ever, be  avoided  ;  and  the  application  should  be  restricted  to  the  right  side  of 
the  body,  in  order  to  escape  the  risk  of  arresting  the  movement  of  the  heart 
by  the  passage  of  electricity  through  the  enfeebled  organ.  For  the  use  of 
electricity,  the  best  method  consists  in  placing  one  electrode  over  the  track  of 
the  right  phrenic  nerve,  in  the  neck,  while  the  other  electrode  is  applied  to 
the  wall  of  the  thorax  over  the  sixth  intercostal  space  on  the  right  side  of  the 
body.  Electrical  stimulation  should  be  associated  with  the  attempt  to  pro- 
duce artificial  respiration  by  Howard's  method — the  electrical  circuit  being 
completed  during  the  elevation  of  the  ribs,  and  interrupted  during  the  time 
of  their  descent.     Insufflation  has  been  recommended  as  a  means  of  filling  the 


416  ANAESTHETICS    AND   ANAESTHESIA. 

lungs  with  air ;  but  if  performed  in  the  ordinary  way,  it  is  likely  to  distend 
the  stomach  rather  than  the  lungs.  If  a  flexible  tube  be  passed  through  the 
glottis  into  the  trachea,  or,  more  easily,  through  a  tracheal  opening,  the  lungs 
may  then  be  easily  tilled  with  air.  But  such  manoeuvres  consume  valuable 
time.  Complete  inversion  of  the  body,  so  that  the  head  shall  be  thoroughly 
depressed,  affords  the  most  speedy  and,  certainly,  one  of  the  surest  means  of 
relief  when  cardiac  syncope  is  exhibited.  Tested  in  the  physiological  labora- 
tory upon  the  lower  animals,  in  whom  chloroform  had  produced  apparent 
death,  this  method  of  resuscitation  has  in  numerous  cases  yielded  very  con- 
spicuous results.  Unfortunately,  however,  the  energy  of  certain  anaesthetic 
substances  is  so  great  that  no  degree  of  vigilance  can  obviate  danger,  nor  can 
the  most  scientific  methods  of  relief  always  effect  a  restoration  when  the 
patient  has  ceased  to  breathe.  The  only  real  approach  to  safety,  the  only 
irreproachable  course  of  action,  lies  in  complete  abstinence  from  these  potent 
drugs.  The  administration  of  atropine  previous  to  the  commencement  of  in- 
halation has  been  recommended  with  a  view  to  protection  against  syncope  by 
its  stimulant  effect  upon  the  heart.  Though  it  be  a  fact  that  the  drug  serves 
to  accelerate  the  cardiac  contractions,  it  certainly  has  a  paralyzing  effect  upon 
the  pneumogastric  nerve  connections  of  the  heart ;  so  that,  while  it  may  theo- 
retically protect  that  organ  from  violent  inhibitory  shocks  transmitted  through 
the  vagi,  it  is  doubtful  whether,  in  medicinal  doses,  it  can  effect  any  benefit 
greater  than  may  result  from  the  action  of  the  anaesthetic  itself. 


Employment  of  Anaesthetics. 

Artificial  Anaesthesia  in  Surgery. — Briefly,  it  may  be  assumed  that 
every  painful  and  long-continued  operation,  upon  a  patient  who  presents  none 
of  the  contra-indieations  already  considered,  constitutes  an  occasion  for  the 
induction  of  artificial  anaesthesia.  By  the  aid  thus  procured,  many  ope- 
rations in  surgery  are  rendered  feasible  which  otherwise  could  rarely  be  pro- 
posed. It  has,  moreover,  been  asserted  that  by  the  use  of  anaesthetics  the 
mortality  after  surgical  operations  has  been  considerably  reduced.  Without 
undertaking  the  discussion  of  a  question  into  which  numerous  other  elements 
must  in  fairness  be  admitted,  it  may  safely  be  conceded  that  the  removal  of 
that  dread  of  pain  which  was  always  so  formidable  an  obstacle  to  early  ope- 
ration for  the  relief  of  disease,  and  the  diminution  of  the  danger  of  exhaus- 
tion by  pain  during  the  time  of  operation,  have  largely  contributed  to  an  in- 
crease of  safety  in  surgery.  It  should  not  be  forgotten,  however,  that  loss  of 
blood  may  be  favored  by  the  action  of  anaesthetics.  The  depressing  effect  of 
the  more  powerful  anaesthetic  substances  may  sometimes  exercise  a  prejudicial 
effect  upon  the  convalescence  of  exceptional  individuals.  Death  may  occur 
during  the  act  of  inhalation.  But,  notwithstanding  all  these  possibilities,  it 
can  scarcely  he  doubted  that  the  sum  of  human  misery  has  been  considerably 
reduced  by  the  employment  of  anaesthetics  in  surgery. 

Artificial  Anaesthesia  in  Obstetrics. — The  employment  of  ether  for  the 
relief  .,1'  |  he  pains  of  child-birth  soon  followed  its  introduction  in  surgery.  Sir 
J.  Y.  Simpson  becameat  once  a  most  enthusiastic  advocate  of  the  new. method, 
whichsoon  became  naturalized  throughout  the  greater  part  of  the  civilized 
world.  Objections  to  (he  practice  have  been  raised  on  the  ground  of  inter- 
ference with  a  natural  process.  It  may  be  conceded  that  in  all  truly  natural 
Labors  the  use  of  anaesthetics  is  superfluous ;  but,  since  the  abnormal  condi- 
tions of  a  partial  civilization  have  introduced  so  large  an  element  of  pain  into 
a  naturally  laborious,  hut  not  necessarily  painful,  process,  the  employment  of 


EMPLOYMENT    OF    ANESTHETICS.  417 

artificial  means  of  relief  is  thoroughly  justified.  Painful  parturition  is  as 
proper  a  subject  for  relief  as  painful  menstruation.  The  proper  stage  of  labor 
for  the  use  of  anaesthetics  may  be  allowed  to  depend  upon  the  degree  of  pain 
by  which  it  is  characterized.  Inhalation  may  be  employed  during  any  stage 
of  confinement.  It  is,  however,  desirable  to  avoid  the  induction  of  profound 
insensibility  during  the  earlier  portion  of  a  labor  which  may  be  prolonged  for 
many  hours.  A  parsimonious  use  of  the  drug  should  be  the  rule,  in  fact, 
during  the  whole  course  of  parturition,  unless  instrumental  interference  be- 
come necessary  for  the  purpose  of  completing  the  delivery.  For  the  produc- 
tion of  anaesthesia,  any  one  of  the  numerous  substances  used  for  this  purpose 
may  be  employed ;  but  the  obstetrical  anaesthetic  par  excellence  is  chloroform. 
Its  convenience,  its  agreeable  properties,  and  the  remarkable  degree  of  safety 
which  has  attended  its  exhibition  under  such  circumstances,  have  all  com- 
bined to  give  it  the  preference  before  all  other  anaesthetics.  For  the  graver 
operations  of  midwifery,  however,  when  complete  insensibility  is  desired, 
sulphuric  ether  should  be  used. 

When  administered  for  the  purpose  of  mitigating  the  severity  of  painful 
uterine  efforts,  it  is  not  necessary  to  reduce  the  patient  to  a  condition  of  silent 
insensibility.  A  few  drops  of  chloroform  vaporized  from  a  handkerchief, 
and  inhaled  at  the  commencement  of  each  pain,  are  usually  sufficient.  Thus 
employed,  it  is  no  unusual  thing  to  hear  a  woman  declare,  at  the  close  of  a 
tedious  labor,  during  which  her  complaints  have  been  most  volubly  uttered, 
that  the  whole  period  has  not  seemed  longer  than  fifteen  minutes.  By  this 
intermittent  method  of  inhalation,  the  stimulant  effect  of  the  drug  is  main- 
tained. If  complete  insensibility  be  induced  during  the  expulsive  stages  of 
labor,  it  may  happen  that  muscular  contraction  is  diminished,  or  even  com- 
pletely arrested.  This  is  the  consequence  of  over-saturation  of  the  reflex 
spinal  centres  with  the  anaesthetic.  The  voluntary  muscles  are  the  first  to 
yield ;  then  follow  the  muscles  which  are  employed  in  semi-voluntary  expul- 
sive acts;  finally,  the  purely  involuntary  muscular  fibres  of  the  uterus.  Ex- 
cepting only  cases  of  operative  interference,  it  is  desirable  that  during  the 
concluding  efforts  of  parturition  the  patient  should  sufficiently  possess  her 
senses  to  assist  the  involuntary  uterine  efforts  by  those  powerful  voluntary 
exertions  which  are  most  efficient  in  a  state  of  consciousness.  If,  however, 
the  sufferings  of  the  patient  combine  with  the  effects  of  partial  anaesthesia  to 
render  her  uncontrollable,  it  is  better  to  produce  complete  insensibility  at  the 
moment  of  delivery.  With  the  birth  of  the  child,  inhalation  should  cease, 
unless  some  unusual  operative  interference  should  be  required.  The  patient 
soon  recovers  consciousness,  and  ordinarily  suffers  very  little  pain  or  discomfort 
during  the  succeeding  day.  For  the  relief  of  after-pains,  chloroform  is  un- 
necessary, opiates  and  chloral  hydrate  usually  sufficing  for  that  purpose. 
The  new-born  infant  rarely  exhibits  any  unfavorable  consequences  from  inha- 
lation by  the  mother.  It  is,  nevertheless,  possible  for  chloroform  to  enter  the 
blood  in  the  placenta,  and  to  find  its  way  into  the  foetal  circulation.  Hoppe- 
Seyler  has  demonstrated  the  presence  of  chloroform  in  the  urine  of  a  new- 
born child.  Long-continued  inhalation  of  large  quantities  of  chloroform  are, 
therefore,  not  without  danger  to  the  life  of  the  infant.  Puerperal  convul- 
sions require  the  induction  of  complete  insensibility,  in  connection  with  other 
appropriate  medical  treatment.  Chloroform  is  ordinarily  employed  for  this 
purpose,  but  when  prolonged  anaesthesia  is  required,  ether  should  be  given. 
The  contra-indications  to  the  use  of  anaesthetics  during  labor  are  the  same 
that  should  preclude  their  use  under  other  circumstances. 

Artificial  Anesthesia  in  Dentistry. — The  search  for  means  of  obviating 
the  pain  attending  the  extraction  of  teeth,  was  the  prime  cause  of  the  utiliza- 
vol.  i. — 27 


418  ANAESTHETICS    AND    ANAESTHESIA. 

tion  of  nitrous  oxide  and  of  ether.  The  defective  apparatus  employed  at  that 
time  was  doubtless  one  of  the  causes  which  led  to  the  disuse  of  Dr.  Wells's 
discovery.  It  was  nearly  twenty  years  after  the  experiments  of  the  Hartford 
dentist,  before  nitrous  oxide  was  finally  established  as  the  dental  anaesthetic. 
During  the  interval,  ether  had  been  introduced  into  the  operations  of  den- 
tistry by  Dr.  Morton,  but  its  place  was  soon  taken  by  chloroform.  The  great 
mortality  consequent  upon  the  use  of  this  agreeable  substance,  produced  a 
reaction  of  feeling  against  its  use,  but  it  was  only  after  Colton  had  shown 
the  superior  safety  of  laughing-gas  that  chloroform  was  tinally  abandoned  by 
the  dental  profession.  The  brevity  of  the  period  of  insensibility  produced  by 
nitrous  oxide,  especially  commends  its  employment  for  all  operations  as  short 
as  the  extraction  of  a  tooth.  For  the  major  operations  of  dentistry,  ether  is 
generally  preferred. 


Local  Anesthesia. 

Numerous  attempts  have  been  made  to  escape  from  the  dangers  of  general 
anaesthesia,  by  the  substitution  of  local  anaesthetic  and  refrigerant  applica- 
tions, for  inhalation  of  generally  stupefying  vapors.  The  well-known  effects 
of  cold  were  thus  utilized  by  James  Arnott.  Freezing  mixtures  of  ice  and 
salt  (two  parts  of  pounded  ice  and  one  of  salt),  applied  to  the  surface  of  the 
body,  soon  produce  congelation  of  the  part.  The  skin  turns  white  and  tal- 
lowy, and  the  part  becomes  completely  insensible.  It  is  necessary  to  apply 
the  mixture  in  a  gauze  bag,  to  permit  the  free  escape  of  the  resulting  liquid. 
Unfortunately,  the  great  difficulty  of  limiting  the  extent  of  refrigeration 
must  always  serve  to  restrict  the  usefulness  of  this  method.  If  it  be  desired 
to  produce  insensibility  extending  to  the  deeper  parts  of  a  limb,  it  will  be 
difficult  to  dispense  with  a  degree  and  a  duration  of  cold  which  must  en- 
danger the  vitality  of  the  superficial  tissues.  Arnott's  method,  therefore,  has 
found  comparatively  little  favor,  and  local  anaesthesia  was  not  generally  em- 
ployed until  13.  W.  Richardson  (in  1866)  introduced  to  English  surgeons  the 
method  of  producing  local  anaesthesia  by  the  concentration  of  an  ethereal 
spray  upon  the  part  to  be  deprived  of  sensibility.  This  operation  is  easily 
performed  with  an  ordinary  hand-ball  atomizing  apparatus.  The  rapid 
evaporation  of  ether  thus  pulverized,  produces  refrigeration  of  the  tissues 
with  which  it  is  brought  in  contact,  by  abstraction  of  the  heat  which  they 
contain.  For  this  reason  the  more  volatile  ethers  are  to  be  preferred. 
Richardson  employed  a  mixture  of  anhydrous  ether,  sp.  gr.  0.720,  and  amylic 
hydride.  Henry  J.  Bigelow,  of  Boston,  recommended  the  use  of  rhigolene, 
one  of  the  products  resulting  from  the  distillation  of  petroleum.  Its  specific 
gravity  is  only  0.625,  and  the  liquid  will  boil  in  the  palm  of  the  hand.  Com- 
plete congelation  of  the  tissues  lenders  it  difficult  to  operate  upon  them  in 
the  usual  way.  Richardson  finds  it  necessary  to  discard  the  knife,  and  to 
supply  its  place  with  curved  scissors.     It  is  not  easy  to  discover  the  severed 

bl (vessels  in  a  mass  of  frozen  hYsh,  and  their  ligation  after  the  parts  have 

thawed  is  always  painful.     For  all  the  graver  operations  of  surgery,  general 
anaesthesia  must  therefore  be  preferred. 

Carbonic  acid  gas  has  been  used  from  time  immemorial  as  a  local  anodyne. 
The  stone  of  Memphis,  and  the  familiar  yeast  poultice,  owe  their  virtues  to 
'la'  local  anaesthetic  effect  of  this  gas.  The  good  effects  of  aerated  waters, 
effervescent  wines,  kumyss,  and  fermenting  paste,  in  irritable  conditions  of 
the  gastric  mucous  membrane,  arc  in  great  measure  due  to  the  carbonic  acid 
which  they  contain.  For  a  brief  period  the  pains  of  uterine  cancer  have  been 
alleviated  by  injection  of  water  charged  with  this  gas. 


OTHER    MODES    OF    PRODUCING   ANESTHESIA.  419 

The  effect  of  the  local  application  of  the  ethereal  anaesthetics  is  exceedingly 
variable,  depending  chiefly  upon  the  degree  of  volatility  of  the  substance. 
Chloroform  is  for  this  reason,  as  well  as  for  its  own  intrinsic  qualities,  more 
potent  than  ether.  When  hindered  from  evaporation  by  covering  the  part 
with  oiled  silk,  the  local  effect  of  the  anaesthetic  is  greatly  intensified.  As  a 
general  rule,  the  more  rapid  the  evaporation  of  the  substance,  the  less  per- 
sistent is  its  anaesthetic  effect.  Diluted  with  oil,  or  combined  with  unguents, 
the  powerful  agents,  like  chloroform,  may  be  employed  with  excellent  effect 
for  the  relief  of  dermal  pains  and  superficial  neuralgias.  Pure  chloroform 
applied  to  the  skin  produces  a  powerful  counter-irritant  effect  by  virtue  of  its 
directly  stimulant  action  upon  the  cutaneous  nerves  and  capillaries.  The 
burning  sensation  thus  aroused  is  soon  succeeded  by  cessation  of  pain,  due  in 
part  to  the  local  stimulation,  and  in  part  to  the  subsequent  diminution  of 
sensibility  in  the  affected  nerves.  Relief  thus  obtained  is,  however,  not  very 
permanent,  and  is  restricted  to  superficial  neuralgias  alone.  For  the  induc- 
tion of  insensibility  sufficient  for  the  painless  performance  of  the  major  opera- 
tions of  surgery,  general  anaesthesia  must  be  employed. 


Other  Modes  of  Producing  Anesthesia. 

Anesthesia  by  the  Aid  of  Electricity. — An  American  dentist,  Dr.  J.  B. 
Francis,  attempted,  in  1857,  to  annul  the  pain  of  extracting  teeth  by  passing 
an  electrical  shock  through  the  tooth  at  the  instant  of  its  evulsion.  After 
numerous  trials,  it  became  clearly  evident  that  this  method  could  avail 
nothing  except  by  substitution  of  one  form  of  pain  for  another.  The  opera- 
tion was  soon  abandoned,  and  the  success  of  nitrous  oxide  in  dentistry  has 
nearly  obliterated  the  recollection  of  electrical  anaesthesia.  The  attempt  to 
produce  local  anaesthesia  in  surgical  operations,  by  connecting  the  knife  with 
one  of  the  rheophores  of  an  electrical  apparatus,  fared  no  better.  The  com- 
bined action  of  electricity  and  local  anodynes  has  been  proved  to  owe  all  its 
efficacy  to  the  action  of  the  drugs  placed  in  contact  with  the  skin,  and  not  at 
all  to  the  electrical  current. 

Anesthesia  by  Rapid  Respiration. — A  method  of  producing  insensibility 
by  rapid  breathing,  sufficient  for  the  painless  performance  of  minor  surgical 
operations,  has  been  suggested  [by  Dr.  Bonwill  and  Dr.  A.  Hewson].  Since 
the  partial  anaesthesia  thus  induced  is  largely  dependent  upon  accumulation 
of  blood  in  the  veins,  overcharging  the  vessels  of  the  brain  with  imperfectly 
oxygenated  blood,  the  method  cannot  be  commended.  In  elderly  subjects 
with  brittle  bloodvessels,  cerebral  hemorrhage  might  thus  be  occasioned. 
Local  anaesthesia  should  be  preferred  to  this  method.  It  is  not  improbable 
that  some  of  the  cases  of  insensibility  to  pain  which  are  placed  in  this  cate- 
gory, may  be  really  examples  of  self-hypnotism. 

Anesthesia  by  Intra-venous  Injections. — Ether,  chloral,  and  chloroform, 
have  been  frequently  administered  by  hypodermic  injection  as  remedies  for 
neuralgia,  and  their  effects  have  been  highly  esteemed  by  certain  observers. 
The  pain  which  attends  the  act  of  injection,  and  the  subsequent  danger  of 
abscess,  or  worse,  has  prevented  the  wide  extension  of  this  method.  Dr.  Ore, 
of  Bordeaux,  consequently  (1872)  recommended  the  use  of  chloral  by  intra- 
venous injection,  as  a  means  of  producing  surgical  anaesthesia.  By  the  aid  of 
a  properly  adapted  canula  and  syringe,  he  slowly  introduced  into  a  superficial 
vein  four  to  ten  grammes  of  chloral  hydrate,  dissolved  in  three  to  five  parts 


420  ANESTHETICS    AND   ANAESTHESIA. 

of  water.  After  a  period  of  time  varying  from  six  to  forty  minutes,  the 
patient  became  completely  insensible,  and  continued  in  this  state  for  a  con- 
siderable time.  In  fifty-three  cases  reported,  the  shortest  period  of  anaesthesia 
was  ten  minutes ;  the  longest  was  three  hours.  Two  deaths  occurred — one 
without  any  visible  lesion,  the  other  in  consequence  of  suppurative  phlebitis. 
The  difficulties  and  the  danger  of  this  method  are  thus  sufficiently  indicated. 

Use  of  Anesthetic  Mixtures. — The  risks  of  cardiac  syncope  and  respira- 
tory paralysis  which  attend  the  use  of  chloroform  and  the  stronger  anaesthetics, 
have  occasioned  the  suggestion  of  various  mixtures  designed  to  stimulate  the 
cardiac  and  respiratory  nervous  centres  during  the  act  of  inhalation.  Oil  of 
turpentine  has  been  added  to  chloroform  with  alleged  successful  results.  At- 
tenuations of  chloroform  with  alcohol  and  sulphuric  ether,  have  been  extensively 
employed.  Billroth  uses  a  mixture  containing  three  parts  of  chloroform  and 
one  part  each  of  sulphuric  ether  and  alcohol.  The  London  Chloroform  Com- 
mittee recommended  (1864)  a  mixture  composed  of  ether  three  parts,  chloro- 
form two  parts,  and  alcohol  one  part.  Experiments  with  frogs  were  said  by 
Sansom  to  prove  that  these  animals  could  not  be  killed  with  chloroform  after 
they  had  inhaled  the  vapor  of  alcohol.  These  mixtures,  however,  do  not 
obviate  all  danger  in  the  human  subject.  Several  deaths  have  occurred 
during  their  administration.  A  mixture  of  amylic  nitrite  and  chloroform,  in 
the  proportion  of  sixteen  drops  to  the  ounce,  has  been  recommended.  Amylic 
nitrite  stimulates  the  heart,  and  produces  a  special  impulsion  of  blood  to  the 
head.  It  has,  therefore,  been  urged  that  medullary  paralysis  cannot  occur 
while  under  its  influence.  For  brief  operations  this  method  has  been  satis- 
factory, but  it  is  an  open  question  whether  the  prolonged  inhalation  of  such  a 
mixture  may  not  be  quite  as  dangerous  as  the  use  of  chloroform  alone. 

Successive  inhalations  of  nitrous  oxide  and  of  ether  vapor  have  been  em- 
ployed, chiefly  in  England,  by  Mr.  Clover.  The  patient  is  rendered  insensible 
with  laughing-gas,  and  the  condition  of  anaesthesia  is  then  maintained  by  the 
substitution  of  ether  or  any  other  anaesthetic  vapor.  This  method  has  given 
good  results,  but  it  necessitates  the  use  of  a  complicated  inhaling  apparatus. 

Belladonna,  or  atropine,  has  been  administered,  in  concurrence  with  the 
inhalation  of  chloroform,  to  counteract  the  tendency  to  syncope  while  in  the 
anaesthetic  state.  Theoretically  useful,  it  is  hardly  probable  that  a  medicinal 
dose  of  atropine  would  be  sufficient  to  protect  against  a  fatal  dose  of  chloro- 
form. The  similar  employment  of  morphine  was  introduced  in  1863  by  Nuss- 
baum,  who  discovered  that  surgical  anaesthesia  could  thus  be  prolonged  for 
several  hours.  Bernard  soon  observed  the  same  phenomena  in  the  lower 
animals.  Extending  these  observations  to  the  human  species,  he  determined 
the  fact  that  moderate  doses  of  morphine,  injected  hypodermically  half  or 
three-quarters  of  an  hour  before  inhalation,  rendered  the  induction  of  anaes- 
thesia less  difficult,  and  caused  it  to  be  attended  with  less  than  ordinary 
excitement.  Injection  immediately  before  inhalation  augmented  the  period 
of  excitement.  Large  doses  of  morphine  caused  danger  of  death  by  asphyxia 
while  under  the  influence  of  chloroform.  This  method  of  treatment  is  espe- 
cially useful  in  the  management  of  drunkards  and  other  patients  who  are 
unduly  excited  by  anaesthetics.  When  small  doses  of  morphine  are  employed, 
the  danger  of  death  during  anaesthesia  is  not  materially  affected ;  but  large 
doses  of  the  drug  mU\  greatly  to  the  peril  of  this  condition.  Chloral  hydrate 
has  sometimes  been  administered  previously  to  the  inhalation  of  chloroform. 
The  period  of  excitement  is  thus  abolished ;  but  opinions  are  divided  con- 
cerning the  safety  of  patients  thus  exposed  to  the  concurrent  action  of  two 
such  potent  drugs. 

Claude  Bernard  and  others  have  observed  that  when  morphine  is  injected 


HYPNOTISM.  421 

hypodermically,  before  the  inhalation  of  sulphuric  ether,  the  period  of  excite- 
ment is  prolonged  and  rendered  more  tempestuous,  and  the  subsequent  head- 
ache and  nausea  are  greatly  aggravated.  A  similar  association  of  chloral 
hydrate  and  sulphuric  ether  gives  a  less  unpleasant  result.  Insensibility 
endures  for  a  longer  time  than  when  ether  alone  is  employed.  Vomiting, 
however,  is  very  common,  and  the  subsequent  prostration  and  headache  are 
considerably  aggravated. 

Hypnotism. — Certain  persons  are  physically  constituted  in  a  manner  which 
leaves  their  nervous  system  extraordinarily  liable  to  disturbance  of  the  co-or- 
dinating and  connective  portions  of  the  apparatus.  Accidentally  observed  at 
intervals  during  all  ages  of  the  world,  this  fact  has  been  made  the  basis  of 
numerous  forms  of  superstition.  Brought  into  notoriety  by  Mesmer,  the 
phenomena  of  hypnotism  were  carefully  investigated  by  Dr.  James  Braid, 
of  Manchester,  between  the  years  1843  and  1852.  Recently  his  experiments 
have  been  repeated  by  the  German  phj'siologists,  Heidenhain  and  Weinhold. 
By  causing  a  susceptible  person  to  gaze  intently  for  several  minutes  upon  any 
bright  object  placed  before  the  eyes,  within  the  limits  of  distinct  vision,  a 
condition  of  somnambulism,  or  even  of  catalepsy,  may  be  induced.  In  this 
condition  the  body  becomes  insensible  to  painful  impressions,  and  the  volun- 
tary functions  of  the  brain  may  be  completely  inhibited.  The  patient  becomes 
reduced  to  the  condition  of  an  automaton,  evolving  reflex  actions  in  obedience 
to  the  will  of  the  operator.  JSTot  all  individuals  are  thus  susceptible.  Some 
experimenters  have  concluded  that  one  person  in  five  was  capable  of  hyp- 
notism. Heidenhain,  who  experimented  only  upon  males,  found  that  one  in 
twelve  could  be  thus  influenced.  It  is  not  necessary  to  address  the  brain 
through  the  eye  alone.  Gentle  friction  of  the  finger  tips,  or  similar  stroking 
of  the  scalp,  or  passes  of  the  hand  near  the  surface  of  the  patient,  will  pro- 
duce the  desired  result.  A  monotonous  and  continuous  sound  may  also 
induce  this  peculiar  state.  In  certain  cases  a  cataleptic  state  may  be  set  up 
by  simply  rubbing  or  pinching  the  limb  which  is  to  be  affected.  The  patient 
may  retain,  in  certain  cases,  the  faculty  of  speech  and  the  power  of  motion, 
and  yet  be  insensible  to  every  painful  impression.  It  is  while  in  this  con- 
dition that  surgical  operations  may  be  endured  without  any  experience  of 
pain.  The  susceptibility  of  the  patient  to  the  influence  of  the  operator  usually 
increases  with  practice,  until,  at  length,  a  touch  with  the  finger  upon  some 
particular  portion  of  the  body,  or  even  a  glance  of  the  eye,  may  suffice  to 
reproduce  the  hypnotic  phenomena. 

This  degree  of  susceptibility  is  so  frequently  associated  with  ill  health, 
that  indulgence  in  hypnotic  sleep  has  been  generally  considered  injurious  to 
the  patient;  but  the  observations  of  Heidenhain  indicate  that  this  is  not 
necessarily  the  case.  The  nervous  susceptibility  may  coexist  with  vigorous 
health.  The  duration  of  the  hypnotic  paroxysm  is  quite  under  the  control 
of  the  operator.  A  smart  tap  upon  the  shoulder,  friction  in  a  direction  op- 
posite to  the  original  course,  a  puff  of  air  in  the  face,  are  sufficient  to  restore 
the  conscious  sensibility  of  the  patient.  Perrin  relates  a  case  in  which  the 
patient,  from  whom  a  cancerous  breast  had  been  removed  during  the  hypnotic 
trance,  was  permitted  to  sleep  for  forty-eight  hours  before  she  was  awakened. 
She  had  given  no  evidence  of  pain  at  the  time  of  operation,  and  retained  no 
recollection  of  anything  that  had  occurred.  But,  though  it  is  certain  that 
the  anaesthesia  which  forms  one  of  the  phenomena  of  the  hypnotic  state  is 
sufficient  to  admit  of  painless  surgery,  it  is  also  a  fact  that  the  comparatively 
limited  number  of  individuals  who  are  susceptible  must  always  preclude  the 
general  employment  of  hypnotic  anaesthesia  as  a  surgical  resourca 


422  ANAESTHETICS    AND    ANESTHESIA. 

Anaesthesia  by  Compression. — James  Moore  (1784),  and  other  surgeons 
since  his  clay,  have  sought  to  produce  local  insensibility  sufficient  to  abolish 
pain,  by  compressing  the  nerves  of  the  part  to  be  operated  upon.  For  this 
purpose  a  species  of  tourniquet  has  been  employed  by  some,  while  simple 
ligation  of  the  member  has  been  proposed  by  others.  Though  it  is  possible 
thus  to  produce  a  certain  degree  of  numbness,  the  success  of  the  method  has 
been  very  imperfect,  and  the  whole  subject  has  become  a  matter  of  purely 
historical  interest.  [Aug.  Waller  produced  muscular  relaxation  and  anaes- 
thesia by  compressing  the  cervical  portions  of  the  pneumogastric  nerves.] 


Mortality  consequent  upon  Artificial  Anaesthesia. 

It  is  impossible  to  reach  any  degree  of  certainty  regarding  this  matter. 
The  number  of  administrations  since  the  discovery  of  Morton  cannot  be  esti- 
mated, and  the  number  of  cases  which  have  resulted  fatally  cannot  be  ascer- 
tained. Hundreds  of  such  cases  have  been  recorded  in  the  medical  journals, 
but  many  hundred  other  cases  have  never  been  thus  reported.  All  estimates 
based  upon  medical  literature  must,  therefore,  be  regarded  as  approximations 
merely.  Sufficient,  however,  is  known  to  enable  the  surgeon  to  speak  with 
great  assurance  regarding  the  relative  dangers  which  attend  the  employment 
of  different  anaesthetics.  Thus,  it  is  certain  that  chloroform  has  occasioned 
the  vast  majority  of  deaths  which  have  occurred  in  connection  with  artificial 
anaesthesia.  But  chloroform  has  been  so  much  more  generally  employed  than 
any  other  anaesthetic,  that  its  mortality,  other  things  being  equal,  should 
present  a  figure  greater  than  that  of  any  other  substance.  In  Europe,  the 
vast  majority  of  surgeons  have  used  chloroform  alone.  It  is  in  America, 
where  ether  has  been  more  generally  employed,  that  a  comparison  of  mor- 
tality is  more  likely  to  give  definite  information.  Here,  however,  complete 
statistics  are  wanting.  A  combination  of  statistical  tables  is  not  likely  to 
give  additional  information,  because  many  of  the  reported  cases  of  death  are 
repeated  in  the  different  tables,  while  the  sum  total  of  inhalations  is  largely 
imaginary.  The  following  estimates  may  illustrate  the  present  condition  of 
our  knowledge  on  the  subject. 

Dr.  J.  J.  Chisolm,  of  Baltimore,  estimates  (1877)  that  among  over  250,000 
recorded  administrations  of  chloroform,  only  twelve  deaths  had  occurred.  But, 
since  over  three  hundred  fatal  cases — Dr.  Turnbull  (1879)  gives  a  total  of 
three  hundred  and  seventy — have  been  recorded,  if  these  had  been  added  to 
Dr.  Chisolm's  collection,  his  estimate  of  the  ratio  of  mortality  would  have 
been  seriously  affected.  Prof.  E.  Andrews,  of  Chicago  (1870),  collected 
117,078  cases  of  chloroform  inhalation  with  43  deaths,  giving  a  ratio  of  1  to 
2723.  Among  92,815  cases  of  ether  inhalation  were  4  deaths,  giving  a  ratio 
of  1  to  23,204.  A  mixture  of  chloroform  and  ether,  used  in  11,17(3  cases,  caused 
2  deaths,  giving  a  ratio  of  1  to  5588.  Bichloride  of  methylene,  used  in  7000 
eases,  caused  one  death.  7>.  Coles,  of  Virginia,  reported,  on  the  basis  of  Eng- 
lish and  American  statistics,  the  following  figures:  Ether,  4  deaths  in  92,815 
inhalations  ;  ratio,  1  to  23,204.  Chloroform,  52  deaths  in  152,260  inhalations: 
ratio,  1  to  2873.  Mixture  of  chloroform  and  ether,  2  deaths  in  11,176  inhala- 
tions ;  ratio,  1  to  5588.  Bichloride  of  methylene,  2  deaths  in  10,000  inhalations; 
ratio,  1  to  5000.  Richardson  collected  from  English  hospital  statistics,  between 
the  years  18  18  and  1869  inclusive,  a  report  of  35,165  administrations  of  chlo- 
roform, with  1  1  deaths,  giving  a  ratio  of  1  to  3196.  Squibb  has  estimated  the 
ratio  of  deaths  by  chloroform  published  in  American  journals  at  1  to  11,764. 
Assuming  thai  only  half  the  fatal  cases  are  reported,  this  would  give  a  ratio 
of  1  to  5882.     A  more  favorable  showing  is  made  by  the  Royal  Infirmary  of 


DEATH    FROM    ANESTHESIA.  423 

Edinburgh,  where  it  is  reported  that  during  a  period  of  ten  years  only  one 
death  occurred  in  an  estimated  total  of  36,500  administrations  of  chloroform. 
Rendle  estimates  that  in  twenty  of  the  principal  London  hospitals  chloroform 
is  administered  about  eight  thousand  times  each  year,  with  a  mortality  oi 
three  per  annum.  This  would  }'ield  a  ratio  of  1  to  2666,  which  agrees  very 
closely  with  Richardson's  later  estimates. 

The  well-known  assertion  that,  during  the  Crimean  war,  not  a  single  fatal 
ease  of  anaesthesia  occurred  among  the  20,000  patients  who  were  chloroformed 
in  the  French  army,  may  be  received  with  a  certain  degree  of  reserve,  for,  in 
military  practice,  it  is  not  always  easy  to  assign  due  weight  to  the  different 
causes  which  may  co-operate  to  produce  a  fatal  result.  It  is  admitted  by  the 
highest  American  authorities  that,  during  the  war  of  the  rebellion,  seven 
fatal  cases  resulted  from  eighty  thousand  inhalations  of  chloroform,  giving  a 
ratio  of  1  to  11,448.  Kappeler  reports  for  himself  and  for  three  other  Ger- 
man surgeons — Billroth,  Xussbaum,  and  Konig — about  thirty-nine  thousand 
administrations  of  chloroform,  with  but  two  fatal  cases.  This  would  give  a 
ratio  of  1  to  19,500.  The  same  author  admits  the  insufficiency  of  German  re- 
ports concerning  the  mortality  after  use  of  chloroform.  Much  allowance  must 
be  made  for  the  personal  equation  of  each  surgeon  in  estimating  the  value  of 
individual  experience  in  this  matter.  If  now  the  above  statistics,  excluding 
the  earlier  tables  of  Andrews  and  Coles,  be  consolidated,  a  total  of  218,165 
inhalations  of  chloroform  gives  a  mortality  of  twenty-four  cases.  This  yields 
a  ratio  of  1  to  9090,  which  is  probably  the  most  favorable  award  that  can  be 
made  to  chloroform.     (See  Note,  p.  433.) 

Information  regarding  the  actual  mortality  caused  by  sulphuric  ether,  is  no 
more  easily  discovered  than  in  the  case  of  chloroform.  Kappeler  could  dis- 
cover only  thirteen  fatal  cases  assigned  to  ether,  and  of  these  thirteen,  only 
four  could  without  contradiction  be  ascribed  to  the  influence  of  ether  alone. 
Turnbull  has  collected  the  histories  of  eighteen  cases  which  proved  fatal  after 
the  inhalation  of  ether ;  but  of  these  only  nine  cases  can  be  fairly  charged  to 
the  anaesthetic.  It  is  probable  that  the  ratio  fixed  by  Dr.  Andrews  (1  to 
23,204)  expresses  very  nearly  the  actual  risk  from  ether  inhalation.  It  should 
be  observed  in  this  connection,  that  such  statistical  estimates  take  no  cogniz- 
ance of  the  innumerable  cases  in  which  alarming  symptoms,  rarely  noted  after 
ether,  present  themselves  during  the  course  of  anaesthesia  from  chloroform. 

Very  little  is  known  regarding  the  comparative  dangers  which  attend  the 
use  of  the  majority  of •  anaesthetic  substances.  Many  of  them  have  caused 
death  at  an  early  period  in  the  history  of  their  employment,  so  that  they 
have  been  laid  aside  before  their  fatality  could  be  justly  estimated.  There 
appears  to  be  good  reason  for  the  belief  that  the  lethal  energy  of  an  anaes- 
thetic is  closely  related  to  the  molecular  weight  of  the  substance — increasing 
directly  as  its  weight  increases.  The  presence  of  the  haloid  elements  also 
adds  greatly  to  the  deadly  efficiency  of  an  anaesthetic  compound.  Nitrous 
oxide,  in  spite  of  its  asphyxiating  property,  is  the  safest  of  all  ana?sthetics  for 
brief  operations.  This  gas  has  been  administered  more  than  a  million  times, 
with  but  seven  fatal  cases.  Used  according  to  the  method  of  Bert  [admin- 
istered in  a  chamber  of  compressed  air  in  mixture  with  oxygen  gas],  it  is 
theoretically  as  harmless  as  atmospheric  air. 


Post-mortem  Appearances  after  Death  from  Artificial  Anesthesia. 

Excluding  the  rare  cases  of  asphyxia  in  which  death  has  been  occasioned 
by  the  intrusion  of  a  foreign  body  into  the  larynx  or  trachea,  and  the  equally 
rare  cases  in  which  suffocation  may  have  been  caused  by  the  use  of  an  ill-con- 


424  ANESTHETICS    AND    ANESTHESIA. 

structed  inhaler,  the  autopsies  of  the  victims  of  anesthesia  present  nothing 
positive  or  characteristic.  In  such  cases,  death  is  the  consequence  of  disturb- 
ance of  the  nervous  apparatus  concerned  in  the  acts  either  of  respiration  or 
of  circulation.  The  changes  which  have  produced  the  result  are  intra-niole- 
cular,  and  are  consequently  beyond  the  reach  of  our  senses. 


Anesthetic  Substances. 

The  majority  of  alcohols  and  ethers  are  probably  endowed  with  anaesthetic 
properties.  The  number,  however,  of  such  compounds  which  are  capable  of 
use  in  a  manner  to  exhibit  this  quality,  is  comparatively  limited.  The  fol- 
lowing; list  includes  all  that  have  been  tested  with  any  degree  of  precision. 
Besides  these,  a  variety  of  substances  which  do  not  belong  to  the  class  of 
alcohols  and  ethers,  are  known  to  possess  anaesthetic  properties.  Nitrous 
oxide,  carbonic  anhydride,  and  various  hydrocarbons,  are  examples  of  these 
bodies.  It  is  not  unlikely  that  all  substances  which  possess  antiseptic  qualities 
are  also  capable  of  producing  artificial  ansesthesia,  if  sufficiently  diluted. 
There  is  wide  room  for  experiment  and  observation  in  this  field  of  investiga- 
tion. The  classification  here  adopted  is  furnished  by  Miller's  Elements  of 
Chemistry  (fifth  edition).  The  formula?  and  the  descriptions  of  the  different 
substances  are  derived  either  from  the  same  source  or  from  Watts's  Dictionary 
of  Chemistry. 

I.  Hydrocarbons  and  their  Derivatives. 

From  petroleum  and  from  coal,  certain  binary  compounds  of  carbon  and 
hydrogen  may  be  separated  by  distillation.  These  are  either  gaseous  and 
present  in  illuminating  gas,  or  liquid  and  separable  by  fractional  distillation 
from  the  kindred  compounds  with  which  they  are  associated  in  crude  petro- 
leum. A  number  of  these  substances  have  been  isolated,  and  separately 
tested  in  the  production  of  artificial  anaesthesia.  Others,  like  keroselene, 
have  been  used  in  their  natural  combinations. 

The  lowest  member  of  the  series  is  Methane,  CIT4,  sometimes  called  meihylic 
hydride,  marsh  gas,  or  light  carburetted  hydrogen.  It  is  one  of  the  products 
of  the  destructive  distillation  of  w^ood,  peat,  soft  coal,  and  other  allied  sub- 
stances. It  is  one  of  the  principal  constituents  of  illuminating  gas.  It  is  a 
colorless,  inodorous,  tasteless  gas,  sp.  gr.  0.5576,  respirable  with  safety  if 
diluted  with  air.  It  is  never  thus  used,  unless  by  accidental  breathing  of 
coal  gas.  The  derivatives  of  this  radical  are  among  the  most  important 
an;esthetics. 

Ethane,  C2IIfi,  Ethylic  hydride,  or  Dimethyl,  is  a  tasteless,  and  odorless  gas 
with  a  specific  gravity  of  1.075.  It  is  chiefly  interesting  as  the  radical  of  the 
ethylic  scries  of  alcohols,  aldehydes,  ethers,  etc. 

Tetrane,  C4HI0,  Butane,  Diethyl,  Butylic  hydride,  is  a  liquid  derived  by 
fractional  distillation  from  petroleum.  The  vapors  must  be  condensed  at  a 
low  temperature,  for  the  boiling  point  of  the  liquid  is  1°  C.  (33°.8  F.).  Dis- 
solved in  naphtha,  the  solution  constitutes  rhigolene,  a  colorless  liquid  which 
evaporates  with  great  rapidity,  boiling  in  the  palm  of  the  hand.  It  has  been 
used  tor  the  production  of  local  ansesthesia  by  the  evaporation  of  its  spray. 
Keroselene  is  a  colorless  liquid,  with  a.  variable  composition,  derived  by  dis- 
tillation from  petroleum.  It  is  chiefly  composed  of  higher  members  of  the 
paraffin  series,  such  as  amylic,  caprylic,  cenanthylic,  laurylic,  myristilic  and 
palmitylic    hydrides.      Inhalation   of  its  vapor   produces   disagreeable  ant  I 


ANESTHETIC    SUBSTANCES.  425 

alarming  symptoms,  so  that  it  may  be  justly  discarded  from  the  list  of  useful 
anaesthetics. 

Pentane,  C5His,  Amylic  hydride,  is  a  colorless  liquid,  boiling  between  37° 
and  39°  C.  (98°.6  and  102°.2  F.).  Its  specific  gravity  is  0.626.  It  is  one  of 
the  constituents  of  naphtha  and  of  rhigolene.  Inhalation  of  its  vapor  is  fol- 
lowed by  speedy  anaesthesia,  without  disagreeable  consequences.  It  has  been 
successfully  used  in  dental  surgery,  but  its  extreme  volatility  is  an  objection 
to  its  general  employment. 

Octane,  C8H1s,  Caprylic  hydride,  has  also  been  isolated  from  keroselene  or 
from  petroleum.  It  is  a  colorless  liquid,  with  a  specific  gravity  of  0.728.  Its 
boiling  point  is  uncertain;  115°-125°  C.  (239°-257°  F.).  Administered  to 
animals,  it  produces  a  long  period  of  excitement,  often  accompanied  by  vom- 
iting. 

The  substances  above  mentioned  belong  to  the  paraffin  series  of  hydro- 
carbons. The  olefin  series  of  hydrocarbons  has  yielded  two  substances  whose 
anaesthetic  properties  have  been  recognized — ethylene  and  amylene. 

Ethylene,  C2II4,  Olejiant  gas,  Heavy  carburetted  hydrogen,  Elayl.  This  is 
one  of  the  most  important  luminous  constituents  of  coal-gas.  It  is  a  trans- 
parent, colorless  gas,  with  a  faint,  sweetish,  alliaceous  odor,  and  is  soluble  in 
about  12  times  its  bulk  of  cold  water.  Its  specific  gravity  is  0.978.  Liquefied 
under  great  pressure,  it  remains  unfrozen  at  — 110°  C.  ( — 166°  F.).  Asso- 
ciated with  methane,  butylene,  acetylene,  hydrogen,  carbonic  oxide,  and  a 
variable  volume  of  impurities,  it  constitutes  a  part  of  the  gaseous  mixture 
used  for  illuminating  purposes.  Illuminating  gas,  when  inhaled  in  consider- 
able quantity,  produces  muscular  rigidity,  contraction  of  the  pupils,  injection 
of  the  cutaneous  vessels,  rapidity  of  the  pulse,  snoring  respiration,  and  com- 
plete insensibility.  Continued  inhalation  produces  dilatation  of  the  pupils, 
muscular  relaxation,  vomiting,  and  death.  The  fatal  issue  results  in  part 
from  the  asphyxiating  property  of  the  impurities  contained  in  the  gas,  and 
in  part  from  the  directly  toxic  effect  of  its  various  ingredients. 

Amylene,  CsH10,  Pentylene,  or  Pentene.  Sp.  gr.  0.6549.  Boiling  point, 
39°-42°  C.  (102°.2-107°.6  F.).  A  transparent,  colorless,  mobile  liquid,  with 
an  offensive,  cabbage-like  odor.  It  burns  with  a  luminous  flame,  is  almost 
insoluble  in  water,  but  mixes  in  all  proportions  with  alcohol  or  ether.  It 
may  be  distilled  from  a  mixture  of  zinc  chloride  and  amylic  alcohol,  and  it 
also  exists  as  a  constituent  of  petroleum.  The  condition  of  insensibility  pro- 
duced by  inhalation  of  its  vapor  is  less  persistent  than  the  effect  of  chloro- 
form. Muscular  spasms  are  likely  to  occur  under  its  influence.  Snow 
administered  it  in  more  than  one  hundred  cases ;  but,  two  deaths  occurring 
as  a  consequence  of  its  use,  it  was  entirely  abandoned. 

Hydrocarbons  of  the  Terpene  Series  are  represented  by  Tuiycntine  oil, 
C10II1V  This  is  a  colorless,  mobile  liquid  with  a  peculiar,  aromatic  odor,  and 
is  obtained  by  distillation  of  the  oleo-resinous  juices  of  certain  species  of 
Pinus.  Its  specific  gravity  is  0.86,  and  it  boils  at  150°-160°  C.  (302°-320° 
F.).  It  has  been  recommended  in  combination  with  chloroform  as  a  means 
of  preventing  syncope  during  anaesthesia.  Administered  to  animals,  it  pro- 
duces complete  insensibility  without  unfavorable  consequences.  Its  effects 
are  slowly  evolved,  and  it  sometimes  produces  local  irritation  of  the  respira- 
tory and  urinary  passages. 

Hydrocarbons  of  the  Benzene  Series.  Benzene,  CfiH6,  Benzol,  Phem/lic 
hydride.  Sp.  gr.  at  0°  C.  (32°  F.),  0.8995.  Boiling  point,  80°.5  C.  (176°.9 
F.).  A  colorless,  limpid,  strongly  refracting  liquid,  of  a  peculiar  and  rather 
agreeable  odor.  Its  vapor  is  very  inflammable,  burning  with  a  luminous  and 
smoky  flame.  The  substances  generally  sold  under  the  names  of  benzine  and 
benzoline  are  chiefly  mixtures  of  paraffins,  and  do  not  contain  benzene.     It 


426  ANESTHETICS   AND   ANESTHESIA. 

may  be  obtained  by  the  distillation  of  benzoic  acid  with  calcic  hydrate  at  a 
dull  red  heat,  but  on  the  large  scale  it  is  prepared  from  the  portion  of  coal- 
tar  oil  which  boils  below  100°  C.  (212°  F.).  As  an  anaesthetic  it  may  be 
used  to  produce  insensibility  when  inhaled,  but  it  produces  disagreeable 
sensations,  muscular  twitching,  and  even  convulsions. 

Haloid  Derivatives  of  the  Hydrocarbons. — Monochloromethane,  CH3C1, 
Methylie  chloride.  Sp.  gr.  of  gas,1.736.  Boiling  point,  —22°  C.  (— 7°.6  F.). 
A  colorless  gas,  prepared  by  passing  hydrochloric  acid  into  a  boiling  solution 
of  zincic  chloride  in  twice  its  weight  of  methylie  alcohol.  A  solution  of  this 
gas  in  ordinary  ether  has  been  employed  experimentally  as  an  anaesthetic. 
It  is  an  agreeable  but  not  very  efficient  substance. 

Dichloromethane,  CH„C12,  Methylenic  chloride,  Methylene  bichloride.  Sp. 
gr.  1.36.  Boiling  point," 40°-42°  C.  (104°-107°.6  F.).  A  colorless  liquid, 
with  an  odor  resembling .  that  of  chloroform.  Prepared  by  acting  upon 
monochloromethane  with  chlorine  in  bright  sunshine,  or  by  treating  di-iodo- 
methane,  CH2I2,  with  chlorine.  Its  effects  are  very  similar  to  those  of 
chloroform  inhalation.  Owing  to  the  low  boiling  point  of  the  liquid,  it  can- 
not be  economically  employed  during  very  warm  weather.  Its  effects  are  for 
the  same  reason  very  evanescent.  Four  cubic  centimetres  are  sufficient  to 
produce  insensibility.  No  unpleasant  sensations  ordinarily  accompany  the 
return  to  consciousness.  Vomiting  is  less  frequent  than  after  chloroform  or 
ether.  This  anaesthetic  has  been  extensively  employed  by  Spencer  Wells,  in 
England,  but  other  surgeons  have  been  less  enthusiastic,  and  numerous  deaths 
caused  by  its  administration  have  been  reported  in  the  English  medical 
journals.     It  is,  probably,  little  less  dangerous  than  chloroform. 

Trichloromethane,  CHC13,  Chloroform.  Sp.  gr.  1.497.  Boiling  point  61°  C. 
(142°  F.).  A  colorless,  volatile  liquid,  with  high  refracting  power,  an  agree- 
able, ethereal  odor,  and  a  sweet,  penetrating  taste.  Very  sparingly  soluble  in 
water,  it  dissolves  in  every  proportion  in  alcohol  or  in  ether.  Set  on  fire 
with  difficulty,'  it  burns  with  a  greenish,  smoky  flame.  Pure  chloroform 
should  communicate  no  color  to  sulphuric  acid  when  agitated  with  it.  The 
liquid  should  be  colorless,  and  destitute  of  any  chlorous  odor.  When  evapo- 
rated from  the  hand,  no  unpleasant  odor  should  remain.  Chloroform  is  an 
excellent  solvent  for  sulphur,  phosphorus,  iodine,  fats,  and  resinous  bodies. 
It  is  the  most  perfect  solvent  for  caoutchouc.  Chloroform  is  manufactured  by 
acting  upon  dilute  alcohol  with  chloride  of  lime.  Wood  spirit,  acetone,  oil 
of  turpentine,  and  many  essential  oils,  likewise  yield  it  when  treated  with 
bleaching  powder.  It  may  be  administered  internally  in  the  liquid  form, 
largely  diluted,  in  doses  not  exceeding  four  cubic  centimetres.  Administered 
by  inhalation,  it  may  be  evaporated  drop  by  drop  from  a  napkin  placed  be- 
fore the  face.  The  vapor  must  be  largely  diluted  with  air.  More  than  five 
per  cent,  of  the  vapor  in  the  air  of  respiration  is  liable  to  produce  alarming 
symptoms.  The  agreeable  odor  of  chloroform,  its  pleasing  effects  upon  the 
brain,  the  energy  and  rapidity  of  its  action,  and  the  concentration  of  the 
liquid,  have  rendered  it  the  favorite  anaesthetic.  The  high  rate  of  mortality 
which  accompanies  its  use  has  rapidly  depressed  its  value  in  the  estimation 
of  an  increasing  number  of  surgeons,  and  has  greatly  stimulated  the  search 
for  a  safer  an;csthetie  which  shall  still  possess  the  admirable  qualities  of  chlo- 
roform. 

Tetrachloromethane,  CC14,  Carbonic  tetrachloride.  Sp.  gr.  1.509.  Boiling 
point  78° C.  (172°.4  FA  A  colorless  liquid,  obtained  from  wood  spirit  and 
chloroform  by  the  action  of  chlorine  in  bright  sunshine.  It  is  insoluble  in 
water,  but  soluble  in  alcohol  and  in  ether.  Employed  as  an  anaesthetic,  its 
action  is  less  rapid  and  more  persistent  than  the  action  of  chloroform.  Its 
sensible  effects  are  less  agreeable,  and  its  effect  upon  the  heart  is  more  energetic 


ANAESTHETIC    SUBSTANCES.  427 

than  that  of  chloroform.  It  is  powerfully  irritant  to  the  nervous  system,  pro- 
ducing tonic  and  clonic  convulsions,  rapid  and  irregular  action  of  the  heart, 
and  arrest  of  respiration.  Its  general  action  is  similar  to  that  of  chloroform, 
but  its  depressing  action  upon  the  heart  is  much  greater,  so  that  it  must  be 
considered  a  more  dangerous  substance. 

Iodomethane,  CII3I,  Methylic  iodide.  Sp.  gr.  2.2.  Boiling  point  42°  C. 
(107°. 6  F.).  Vapor  density  4.833.  A  colorless,  mobile  liquid,  of  peculiar 
ethereal  odor,  insoluble  in  water,  prepared  by  distillation  from  a  mixture  of 
100  parts  of  iodine  with  50  parts  of  methylic  alcohol  and  7  parts  of  amor- 
phous phosphorus.  Chemically  pore,  its  vapor  is  respirable  and  anaesthetic; 
but  it  is  exceedingly  unstable,  yielding  excessively  irritating  fumes,  and  pro- 
ducing very  disagreeable  effects. 

Tri-iodomethane,  CHI3,  Iodoform.  Melting  point,  120°  C.  (248°  F.).  A 
product  of  the  action  of  iodine,  in  presence  of  potassic  or  sodic  hydrate  or 
carbonate,  on  ethylic  alcohol,  aldehyde,  acetone,  and  many  other  substances. 
It  exists  in  greenish-yellow,  scale-like  crystals,  with  a  sweetish  taste,  and  a 
peculiar  odor  which  may  be  masked  by  the  oil  of  peppermint.  Its  properties 
are  discutient,  antiseptic,  and  anaesthetic.  Applied  locally,  it  diminishes  the 
sensibility  of  the  skin,  and  of  irritable  surfaces  generally.  All  varieties  of 
unhealthy,  offensive,  and  painful  ulceration  are  benefited  by  its  topical  ap- 
plication. Administered  internally,  in  small  doses,  it  is  rapidly  eliminated 
without  producing  any  signs  of  irritation.  Doses  of  half  a  gramme  (eight 
grains)  produce  in  man  a  diminution  of  the  frequency  of  the  pulse.  If  con- 
tinued for  any  considerable  period  of  time,  somnolence  may  result.  Given  to 
animals — four  grammes  to  a  dog — it  produces  muscular  relaxation,  anaesthe- 
sia, insensibility,  and  death.     Muscular  rigidity  may  also  be  observed. 

Moxochlorethane,  CLH/31,  Etkylic  chloride,  Hydrochloric  ether.  Sp.  gr. 
0.920.  Boiling  point,  12°.18  C.  (53°.92  F.).  Vapor  density,  2.219.  A  thin, 
colorless  liquid,  with  a  pungent,  ethereal  odor,  and  a  sweetish,  aromatic  taste. 
It  is  very  inflammable,  evolving  hydrochloric  acid  from  a  brilliant,  green- 
edged  flame.  It  is  the  first  product  of  the  action  of  chlorine  upon  ethane  in 
disused  daylight.  In  spite  of  its  remarkable  volatility,  this  substance  has 
been  employed  as  an  anaesthetic  in  a  number  of  operations.  Its  general  effects 
correspond  very  closely  with  the  effects  produced  by  ordinary  ether.  Given 
to  rabbits,  it  produces  rapid  anaesthesia,  but  it  has  caused  in  these  animals 
cessation  of  respiration,  and  general  convulsions. 

Dichlorethane,  C2H4C12.  Two  isomeric  dichlorethanes  are  known:  (a)  di- 
chlorethane,  or  ethylenic  chloride,  CII2C1.CII2C1 ;  and  (0)  dichlorethane,  or  ethyli- 
denic chloride,  CH3.CHC12. 

(a)  Mhylenic  chloride,  Ethylene  dichloride,  Dutch  liquid.  Sp.  gr.  1.256. 
Boiling  point,  84°  C.  (183°.2  F.).  Vapor  density,  3.4434.  A  colorless,  neu- 
tral, oily  liquid  with  a  fragrant,  ethereal  odor  and  a  sweetish,  aromatic  taste. 
It  is  formed  by  the  action  of  chlorine  upon  ethylene.  The  resulting  compound 
is  anaesthetic,  but  its  vapor  is  irritating,  and  sometimes  causes  vomiting.  In 
the  lower  animals  it  may  produce  convulsive  movements  without  anaesthesia. 
It  possesses  no  advantages  over  chloroform. 

((3)  Ethylidenic  dichloride,  JEthylidene  chloride,  Ethidene  dichloride.  Sp.  gr. 
1.174.  Boiling  point,  60°  C.  (140°  F.).  Vapor  density,  4.954.  A  colorless, 
oily  liquid,  resembling  chloroform  in  taste  and  odor,  produced  by  acting  on 
monochlorethane  with  chlorine,  and  also  by  treating  aldehyde  with  phosphoric 
pentachloride.  Its  anaesthetic  action  is  very  rapid,  producing  insensibility  in 
one  minute — seldom  requiring  to  be  inhaled  as  long  as  three  minutes.  Ke- 
covery  is  speedy,  and  disagreeable  after-effects  are  rarely  experienced.  The 
heart  is  less  liable  to  depression  under  the  influence  of  ethylidenic  chloride 
than  when  chloroform  is  employed.     It  is,  nevertheless,  a  cardiac  poison,  pro- 


428  ANAESTHETICS    AND    ANESTHESIA. 

ducing  death  by  syncope.  Administered  by  Mr.  Clover  in  one  thousand 
eight  hundred  and  seventy-seven  cases,  it  caused  one  death ;  and  on  three  other 
occasions  the  patient  was  only  saved  by  inversion  and  artificial  respiration. 

Trichlorethane,  C2H3C13,  exists  in  two  isomeric  forms — (a)  trichlorethane, 
CH2C1.CHC12,  and  (?)  trichlorethane,  CH3.CC13. 

(a)  Trichlorethane,  Monochlorethylenchloride.  Sp.  gr.  1.422.  Boiling  point, 
115°  C.  (239°  F.).  A  liquid,  having  an  odor  like  chloroform,  formed  by  the 
action  of  chlorine  on  dichlorethane,  or  by  the  action  of  chlorovinyl  (C2H3C1)  on 
perchloride  of  antimony.  It  is  readily  decomposed  with  potassa  into  potassic 
chloride  and  dichlorethylene.  The  vapor  of  a  few  drops  is  sufficient  to  pro- 
duce rapid  anaesthesia  in  frogs,  pigeons,  guinea-pigs,  and  rabbits.  Dogs 
weighing  five  or  six  kilogrammes  are  rendered  insensible  in  three  to  seven 
minutes  by  the  vapor  of  thirty  to  fifty  drops  of  the  liquid.  The  duration  of 
such  anaesthesia  varies  from  eleven  to  nineteen  minutes.  In  one  case,  reported 
by  Tauber,  of  Jena,  the  pulse  was  considerably  accelerated;  slightly  in  three 
others.  In  no  instance  was  it  retarded.  Respiration  was  either  accelerated 
or  but  very  slightly  diminished.  The  kymographion  exhibited  no  diminu- 
tion of  blood-pressure. 

(j3j  Trichlorethane,  MonochlorethyUdenchloride,  Methylehloroform.  Sp.  gr. 
1.372.  Boiling  point  75°  C.  (167°  F.).  A  liquid,  resembling  chloroform  in 
odor  and  appearance,  produced  by  the  action  of  chlorine  on  monochlorethane. 
With  this  substance,  Tauber,  of  Jena,  has  recently  experimented  upon  animals 
and  upon  himself.  Frogs  and  rabbits  were  quickly  rendered  insensible  with- 
out special  modification  of  either  circulation  or  respiration.  A  dog,  weighing 
five  or  six  kilogrammes  (ten  or  twelve  pounds),  was  rendered  completely  in- 
sensible for  nineteen  minutes  by  the  vapor  of  forty  or  fifty  drops  of  the  liquid. 
Respiration  was  somewhat  accelerated  during  the  period  of  most  profound 
insensibility,  but  the  pulse  was  very  slightly  disturbed.  The  vapor  of  two 
hundred  drops  (twenty  grammes),  administered  to  Dr.  Tauber,  caused  anaes- 
thesia in  five  minutes  and  thirty  seconds.  It  continued  for  ten  minutes. 
There  was  no  preliminary  stage  of  excitement.  Respiration  remained  quiet 
and  normal.  The  pulse  did  not  exceed  84,  and  continued  undisturbed 
throughout  the  experiment.  Recovery  was  attended  with  vomiting,  and 
with  a  feeling  of  discomfort  which  lasted  for  an  hour. 

Aran's  Ether,  C2H3C13  +  C2H2C14,  Ether  ancesthetie.us,  is  a  mixture  of  tri- 
chlorethane and  tetrachlorethane.  Its  specific  gravity  varies  from  1.55  to 
1.6.  Its  boiling  point  is  about  130°  C.  (266°  F.).  In  appearance  and  prop- 
erties it  resembles  chloroform. 

Monobromethane,  C2HsBr,  Ethylic  bromide,  Bromide  of  ethyl,  ITi/drobromic 
ether.  Sp.  gr.  1.4733.  Boiling  point,  40°.7  C.  (105°.26  F.).  'Vapor  density, 
3.754.  A  colorless,  neutral  liquid,  with  ethereal  odor  and  a  disagreeably 
sweetish  taste.  Sparingly  soluble  in  water,  it  mixes  readily  with  alcohol  and 
ether.  It  is  ignited  with  difficulty,  giving  a  green  flame  without  smoke, 
evolving  a  strong  smell  of  hydrobromic  acid.  Its  vapor  is  powerfully  anaes- 
thetic, producing  insensibility  in  animals  in  less  than  a  minute.  Its  effects 
pass  off  very  rapidly.  Circulation  and  respiration  are  profoundly  modified 
by  its  depressing  action.  To  adult  human  beings  it  may  be  administered 
upon  a  napkin  in  doses  of  four  cubic  centimetres  (one  drachm)  at  once.  The 
excessive  volatility  of  the  liquid  requires  almost  total  exclusion  of  air  during 
inhalation.  Owing  to  the  instability  of  the-  substance,  it  is  liable  to  become 
contaminated  with  carbon  bromide  and  free  bromine.  Great  irritation  may 
be  excited  by  inhalation  of  these  impurities.  This  fact,  in  connection  with 
the  recent  occurrence  of  death  in  two  instances  of  its  use,  has  led  to  the  almost 
total  abandonment  of  the  drug  as  a  general  anaesthetic. 


ANAESTHETIC    SUBSTANCES.  429 

Iodethane  C2H5T,  Ethylic  iodide,  Iodide  of  ethyl,  Hydriodic  ether.  Sp.  gr. 
1.97.  Boiling  point  72°. 5  C.  (162°. 5  F.).  Vapor  density,  5.475.  A  colorless, 
ethereal  liquid,  prepared  by  distillation  from  a  mixture  of  ethylic  alcohol, 
amorphous  phosphorus,  and  iodine.  It  soon  decomposes,  turning  red  or 
hrown  from  the  liberation  of  iodine.  Its  vapor  is  useful  in  chronic  bronchitis 
and  in  certain  cases  of  asthma.  It  has  been  occasionally  employed  as  a  gene- 
ral anesthetic,  but  its  instability  is  sufficient  to  disqualify  it  for  such  use. 

Monochlorotetrane,  C,H0C1,  Butylic  chloride.  Sp.  gr.  0.88.  Boiling  point, 
about  70°  C.  (158°  F.).  An  ethereal  liquid,  with  an  odor  recalling  that  of 
chlorine,  may  be  obtained  by  distilling  amylic  alcohol  with  calcic  hypo- 
chlorite. Its  vapor,  administered  to  rabbits,  overpowers  respiration  and 
weakens  the  cardiac  pulsations  until  they  cease  altogether. 

Isobutylic  chloride,  CH(CII3)2CH2C1,  is  a  compound  isomeric  with  the  pre- 
ceding substance.  Its  specific  gravity  is  0.895;  its  boiling  point  is  60°  C. 
(140°  F.).  Prepared  by  treating  isobutylic  alcohol  with  hydrogen  chloride, 
or  with  phosphorus  pentachloride,  it  is  a  limpid  liquid,  with  a  pleasant, 
ethereal,  but  slightly  alliaceous  odor.  Administered  to  frogs,  rabbits,  and 
dogs,  it  produced  anesthesia  in  from  three  to  five  minutes.  Respiration  was 
unaffected,  and  cardiac  pulsation  was  not  weakened. 

Monochloropentane,  C4HnCl,  Amylic  chloride,  Chloride  of  amyl.  Sp.  gr. 
0.699.  Boiling  point  101°  C.  (213°.8  F.).  Vapor  density' 3.8.  '  Three  iso- 
meric monochlorinated  compounds  of  pentane  exist,  differing  slightly  in 
specific  gravity  and  boiling  point.  The  substance  which  is  employed  as  an 
anesthetic  has  been  tested  by  Snow  and  Richardson.  It  is  administered  in 
quantity  similar  to  chloroform,  and  produces  a  gradually  developed  and  long- 
continuing  anesthesia,  without  specially  disagreeable  consequences. 

aIono-iodopentane,  C5HnI.  Amylic  iodide,  Iodide  of  amyl.  Sp.  gr.  1.511. 
Boiling  point  146°  C.  (294°.8  F.).  'Vapor  density  6.675.  A  colorless  liquid, 
with  faint  odor  and  pungent  taste,  turning  brown  on  exposure  to  light.  It  is 
prepared  by  treating  amylic  alcohol  with  iodine  and  phosphorus.  Though 
possessed  of  anesthetic  properties,  its  instability  disqualifies  it  for  practical 
use. 

Xitropentane,  CjHjjXO^  Amylic  nitrite,  Nitrite  of  amyl.  Sp.  gr.  0.877. 
Boiling  point  96°  C.  (205°  F.).  A  clear,  colorless  liquid,  prepared  by  heat- 
ing pure  amylic  alcohol  with  nitric  acid.  It  has  a  peculiar  odor,  suggestive 
of  apples  and  bananas.  Administered  drop  by  drop,  in  vapor,  it  powerfully 
excites  the  heart,  and  dilates  the  bloodvessels,  especially  of  the  head.  The 
stage  of  excitement  is  followed  by  diminution  of  cardiac  energy  and  collapse 
of  the  terminal  vessels.  Consciousness  disappears  before  death  when  the  drug 
is  given  in  poisonous  doses.  Complete  anesthesia  does  not  occur  until  shortly 
before  death.  The  use  of  this  substance  is  specially  indicated  in  diseases 
characterized  by  spasmodic  or  excessive,  tonic  contraction  of  the  vascular 
coats  in  any  part  of  the  body,  such  as  the  angiospastic  variety  of  hemicrania, 
angina  pectoris,  or  epilepsy.  Its  stimulant  effect  upon  the  heart  has  led  to 
its  employment  in  the  syncope  induced  by  chloroform. 

_  Pyrrol,  C4H5N.  Sp.  gr.  1.077.  Boiling  point  133°  C.  (271°.4  F.).  A 
nitro-hydrocarbon  found  "in  coal  tar.  It  is  produced  whenever  animal  or 
vegetable  substances  containing  nitrogen  are  subjected  to  destructive  distilla- 
tion. It  is  a  colorless,  transparent  liquid,  with  a  delightfully  fragrant  odor, 
resembling  chloroform,  but  softer  and  less  pungent.  Its  taste  is  hot  and  pun- 
gent. Administered  to  small  animals,  its  vapor  produces  great  excitement 
and  muscular  spasms,  succeeded  by  imperfect  anesthesia. 


430  ANAESTHETICS    AND    ANAESTHESIA. 


II.  Alcohols. 

Methylic  Alcohol,  CHrOH.  Wood  spirit,  Pyroxylic  spirit.  Sp.  gr.  0.8142. 
Boiling  point  58.6°  C.  (137°.4  F.).  A  limpid,  colorless,  inflammable  liquid, 
with  a  penetrating,  spirituous  odor,  and  a  disagreeable,  burning  taste.  It  is 
usually  prepared  from  the  crude  wood  vinegar  obtained  by  the  dry  distilla- 
tion of  hard  wood  at  a  high  temperature  in  closed  vessels.  Its  vapor  pro- 
duces headache,  dizziness,  and  nausea.  Taken  in  the  liquid  form,  it  may  pro- 
duce intoxication  and  insensibility  resembling  that  produced  by  ordinary 
alcohol. 

Ethylic  Alcohol,  CH3.CH2OII.  Alcohol.  Spirit  of  vine.  Sp.  gr.  0.8095, 
0.7938  at  15°.6  C.  (60°  F.).  Boiling  point,  78°.3  C.  (173°  F.).  Vapor  den- 
sity, 1.613.  A  colorless,  volatile,  inflammable  liquid,  with  an  agreeable, 
spirituous  odor  and  burning  taste,  obtained  by  distillation  from  saccharine 
solutions  which  have  undergone  fermentation.  A  stimulant  in  small  doses, 
large  quantities  of  the  liquid  produce  depression  of  temperature,  enfeeblement 
of  the  heart,  general  anaesthesia,  unconsiousness,  and  even  death  itself. 

Phenol,  CgH6.OH,  Oxybenzene,  Phenylic  hydrate,  Carbolic  acid.  Sp.  gr. 
1.056.  Boiling  point,  182°  C.  (359°.6  F.).  Obtained  by  purification  of  the 
product  of  distillation  of  the  dead  oil  of  coal  tar.  It  crystallizes  in  long 
colorless  needles  which  melt  at  about  39°  C.  (102°.2  F.).  Its  odor  is  charac- 
teristic though  not  disagreeable.  It  is  moderately  soluble  in  water,  and  does 
not  redden  litmus.  It  is  extremely  soluble  in  alcohol,  ether,  acetic  acid, 
carbon  disulphide,  chloroform,  and  hydrocarbons  of  the  benzene  series.  It 
coagulates  albumen,  and  prevents  fermentation  and  putrefaction.  Applied 
to  the  healthy  skin  it  excites  a  burning  sensation,  whitens  the  surface,  and 
produces  local  anesthesia  sufficient  to  render  superficial  incisions  painless. 
Administered  internally  it  produces  acceleration  of  the  circulation  and  respi- 
ration, followed  by  more  or  less  general  ansesthesia.  Poisonous  doses — thirty 
grammes  (an  ounce)  or  more — produce  caustic  effects  in  the  mouth,  oesopha- 
gus, and  stomach,  followed  by  feeble  pulse,  livid  skin,  insensibility,  collapse, 
and  death.  Fatal  consequences  have  followed  the  external  use  of  this  sub- 
stance when  used  in  large  quantities  with  surgical  dressings. 

TrichlorethaldeHydrol,  CC13.CII(0II)2,  Chloral  hydrate.  Boiling  point, 
96°  C.  (204°.8  F.).  Produced  by  the  action  of  chlorine  on  a  well  cooled 
aqueous  solution  of  aldehyde.  It  crystallizes  in  large  monoclinic  prisms, 
soluble  in  water.  Administered  by  the  mouth,  or  injected  into  a  vein,  it 
produces  deep  sleep.  This  action  has  been  attributed  to  its  conversion  into 
chloroform  and  formic  acid  in  the  blood.  There  is,  however,  not  sufficient 
reason  to  accept  this  explanation.  It  reduces  the  temperature,  lessens  blood 
pressure,  lowers  the  rate  of  respiration  and  circulation,  relaxes  spasm,  and 
induces  sleep,  but  does  not  produce  complete  ansesthesia  unless  administered 
in  dangerous  doses.  It  is  a  powerful  irritant  when  applied  locally  to  the 
skin  or  mucous  membranes.  Its  hypodermic  use  is  liable  to  cause  pain  and 
sloughing.  As  a  hypnotic,  it  may  be  given  in  doses  of  one  or  two  grammes 
(fifteen  to  thirty  grains).  Death  has  been  known  to  result  from  ten  grains, 
but  recovery  has  nlso  occurred  alter  taking  165  grains,  or  even  350  grains. 
As  an  anodyne,  chloral  hydrate  is  inferior  to  opium. 

Trichlorobutaldehydrol,  (yi4013.(TI(01i)2,  BvtylcUoral  hydrate.  A  snb- 
stuiicc  closely  resembling  chloral  hydrate  in  appearance,  crystallizing  from 
water  in  thin,  glistening,  white  plates  which  melt  at  78°  C.  (172°.4  F.).  It 
is  prepared  Prom  ethvlic  aldehyde  by  the  action  of  chlorine,  which  first  pro- 
duces trichlorotetraldchyde.  The  addition  of  water  occasions  the  formation 
of  butylchloral  hydrate.     The  effect  of  this  substance  closely  resembles  the 


ANAESTHETIC    SUBSTANCES.  431 

effects  produced  by  chloral  hydrate.  It,  however,  produces  marked  insensi- 
bility of  the  nerves  of  the  head  and  face.  This  has  given  the  drug  a  certain 
reputation  in  the  treatment  of  facial  neuralgia.  The  ordinary  soporific  dose 
is  about  gm.  0.20  (three  grains),  repeated  at  intervals  of  an  hour.  Excessive 
doses  may  prove  fatal  by  arresting  the  movements  of  respiration. 


III.  Ethers. 

Methylic  Ether  or  Oxide  of  methyl,  CITrO.CH3.  A  colorless  gas,  with  a 
pleasant,  ethereal  odor,  it  may  be  condensed  by  cold  or  by  pressure  to  a 
liquid  boiling  at  about  — 21°  C.  ( — 5°. 8  F.).  It  is  not  used  in  surgery,  but 
its  solution  in  ether  has  been  tested  under  the  name  of  methyl-ethylic  ether. 
The  vapor  of  this  substance  produces  anaesthesia  without  agitation,  spasm,  or 
convulsion.  Small  animals  killed  by  its  inhalation  die  from  paralysis  of 
respiration.  Its  odor  and  its  extreme  volatility  furnish  the  principal  objec- 
tions to  its  use. 

Ethylic  Oxide,  C2H3.O.CJIs,  Ethylic  ether,  Ether,  Sulphuric  ether.  Sp.  gr. 
0.736.  Boiling  point,  35°.5"C.  (95°.9  F.).  Vapor  density,  2.586.  A  colorless, 
transparent,  mobile  liquid,  with  a  peculiar,  exhilarating  odor  and  sharp,  burn- 
ing taste,  with  a  cooling  after-taste.  It  is  formed  by  the  action  of  sulphuric 
acid  upon  ethylic  alcohol.  The  primary  effect  of  ether  inhalation  is  excite- 
ment. The  pulse  and  respiration  are  accelerated ;  the  mucous  surfaces  are 
irritated  ;  there  is  a  disposition  to  muscular  movement ;  the  brain  is  excited. 
This  stage  is  soon  followed  by  a  diminution  and  perversion  of  general  sensi- 
bility. The  sense  of  pain  is  overcome  before  the  sense  of  touch.  The  special 
senses  soon  yield ;  the  muscular  apparatus  is  relaxed ;  the  pupils  are  con- 
tracted ;  the  face  suffused ;  the  skin  becomes  moist ;  consciousness  ceases. 
In  this  stage  the  circulation  and  respiration  recede  towards  the  normal 
standard,  and  tend  towards  a  uniform  rate.  In  profound  anaesthesia  the 
respiration  may  become  stertorous  and  slow ;  the  pulse  falls  and  weakens ; 
the  skin  is  cool,  moist,  and  pale — sometimes  cyanotic.  In  the  rare  instances 
of  death  from  inhalation  of  ether,  the  fatal  result  is  due  to  arrest  of  the  func- 
tions of  respiration  and  circulation.  [Under  the  name  of  "first  insensibility 
from  ether,"  Dr.  Packard,  of  Philadelphia,  has  described  a  condition  of  brief 
duration  in  which  certain  operations,  such  as  opening  an  abscess,  can  be  per- 
formed without  pain  to  the  patient,  though  the  administration  of  the  anaes- 
thetic has  not  been  pushed  to  the  extent  of  producing  complete  insensibility. 
A  similar  condition  of  "primary  anaesthesia"  from  the  use  of  chloroform,  has 
been  noticed  by  Dr.  Gibney,  of  New  York.] 

Methylal,  CH2(OCH3)2,  Methylene  dimethyl  ether.  Sp.  gr.  0.8551.  Boiling 
point,  42°  C.  (107°.6  F.).  Vapor  density,  2.625.  A  colorless,  ethereal  liquid, 
obtained  in  small  quantity  by  distilling  methylic  alcohol  with  sulphuric  acid 
and  manganic  peroxide.  It  possesses  decided  anaesthetic  properties,  but  is 
less  agreeable  and  less  manageable  than  chloroform. 


IV.  Ethereal  Salts. 

Ethylic  Nitrate,  C2IIs.N03,  Nitric  ether.  Sp.  gr.  1.112.  Boiling  point, 
85°  C.  (185°  F.).  Vapor  density,  3.112.  A  colorless  liquid  with  an  agree- 
able odor,  and  a  taste  at  first  very  sweet,  but  followed  by  a  bitterish  after- 
taste. It  is  obtained  by  distillation  from  a  mixture  of  alcohol  and  nitric  acid 
with  urea.     The  vapor  of  fifty  or  sixty  drops  produces  anaesthesia,  followed 


432  ANESTHETICS    AND   ANESTHESIA. 

by  such  disagreeable  dizziness,  headache,  and  general  discomfort  that  its  use 
cannot  be  recommended. 

Ethylic  Formate,  C3Ha02,  Formic  ether.  Sp.  gr.  0.918.  Boiling  point, 
54°.9  C.  (130°.8  F.).  Vapor  density,  2.573.  A  colorless  liquid  with  an 
agreeable,  pungent  odor,  formed  by  distilling  a  mixture  of  formic  acid  and 
ethylic  alcohol  with  sulphuric  acid.  It  is  supposed  to  act  by  decomposition 
into  alcohol  and  alkaline  formiates  in  the  blood.  Upon  animals  its  effect  is 
similar  to  that  of  alcohol.  Doses  of  six  or  eight  cubic  centimetres  (a  drachm 
and  a  half  to  two  drachms),  given  to  the  human  subject,  produce  only  drowsi- 
ness. 

Ethylic  Acetate,  C4H802,  Acetic  ether.  Sp.  gr.  0.906.  Boiling  point,  77°  C. 
(170°.6  F.).  Vapor  density,  3.047.  A  colorless  liquid  which  has  a  pleasant, 
fruity  odor  when  diluted  with  alcohol  or  water.  It  is  obtained  by  distilling 
a  mixture  of  ethylic  hydric  sulphate  and  sodic  acetate.  Less  volatile  and  less 
inflammable  than  ordinary  ether,  it  produces  anaesthesia  in  small  animals  with 
less  previous  agitation  than  when  ether  is  used.  It  may  be  employed  in  doses 
similar  to  those  of  sulphuric  ether. 

V.  Aldehydes. 

Ethaldehyde,  CH3.COtI,  Acetic  or  Ethylic  aldehyde,  Aldehyde.  Sp.  gr.  0.801. 
Boiling  point,  22°  C.  (71°.6  F.).  Vapor  density,  1.532.  Produced  by  the 
action  of  nearly  every  oxidizing  agent  on  ethylic  alcohol,  this  substance  is  a 
colorless,  mobile,  inflammable  liquid,  with  a  characteristic,  pungent,  not  dis- 
agreeable odor.  Inhalation  of  its  vapor  produces  a  sense  of  constriction  about 
the  chest,  and  distressing  irritation  of  the  respiratory  passages,  with  a  marked 
tendency  to  arrest  of  respiration.  It  is  a  powerful  anaesthetic,  producing 
insensibility  in  about  two  minutes  ;  but  its  effects  are  disagreeable  and 
dangerous. 


VI.  Ketones. 

Dimethyl  Ketone,  CII3.CO.CH3,  Acetone.  Sp.  gr.  0.814.  Boiling  point, 
56°.3  C.  (133°.3  F.).  Vapor  density,  2.0025.  A  limpid  liquid  possessing  an 
agreeable  odor,  and  a  biting  taste  like  peppermint.  Prepared  by  various 
processes,  it  is  most  conveniently  obtained  by  the  dry  distillation  of  calcic 
acetate.  Its  vapor  is  slightly  anaesthetic  to  frogs.  Inhaled  by  the  human 
subject,  it  produces  soporific  effects  associated  with  dyspnoea  and  irritation 
el'  the  air-passages. 


VII.  Inorganic  Substances. 

Nitrogen,  N.  Sp.  gr.  0.971.  A  colorless,  tasteless,  odorless  gas.  Its  reac- 
1  ion  is  neutral  with  litmus,  and  it  is  neither  inflammable  nor  a  supporter  of 
combustion.  It  may  be  readily  inhaled  in  an  undiluted  form.  It  thus  pro- 
duces simple,  uncomplicated  asphyxia.  Such  insensibility  as  follows  its  inha- 
lation is  merely  one  of  the  preliminaries  of  death  by  asphyxia.  For  this 
reason,  oitrogen  cannol  strictly  be  considered  an  anaesthetic  substance. 

Nitrous  Oxide,  N20,  Laughing  gas.  Sp.  gr.  of  gas,  1.527.  Sp.  gr.  of 
liquid,  0.908.  Boiling  point  of  liquid,  —88°  C.  (— 126°.4  F.).  A  transpa- 
rent, colorless  gas,  with  a  faint,  sweetish  smell  and  taste,  prepared  by  heating 
ammonium  nitrate.     It  may  be  liquefied  by  a  pressure  of  fifty  atmospheres  at 


ANESTHETIC    SUBSTANCES.  433 

7°  C.  (45°  F.).  Inhalation  of  the  gas  produces  both  asphyxia  and  anaesthesia ; 
hence  it  can  be  respired  with  safety  for  a  brief  period  only.  It  rapidly  dis- 
charges oxygen  from  the  blood,  and  produces  death  by  asphyxia.  The  con- 
vulsive phenomena  which  ordinarily  accompany  that  state  are  suppressed  by 
the  anaesthetic  action  of  the  gas  upon  the  convulsive  nerve  centres.  If  mixed 
with  atmospheric  air  during  inhalation,  great  nervous  and  cerebral  exhilara- 
tion is  produced,  without  loss  of  consciousness.  The  action  of  the  undiluted 
gas  is  very  prompt,  and  recovery  is  equally  rapid.  Faul  Bert  has  shown  that 
an  equal  mixture  of  nitrous  oxide  and  common  air,  or  an  equivalent  quantity 
of  oxygen,  inhaled  under  a  pressure  of  two  atmospheres,  will  produce  com- 
plete anaesthesia  without  asphyxia.  Inhalation  of  the  mixture  may  be  safely 
continued  for  an  indefinite  period.  By  this  method  the  blood  receives  enough 
oxygen  to  sustain  life  at  the  same  time  that  it  is  sufficiently  charged  with 
nitrous  oxide  to  produce  anaesthesia. 

Carbonic  Oxide,  CO.  Sp.  gr.  0.967.  A  transparent,  colorless,  inflammable, 
almost  odorless  gas.  It  is  ordinarily  produced  by  the  combustion  of  coal  with 
a  limited  supply  of  oxygen.  Its  action  is  exceedingly  energetic.  The  presence 
of  one  tenth  of  one  per  cent,  of  this  gas  in  the  air  is  sufficient  to  destroy  a 
bird,  and  two  or  three  tenths  of  one  per  cent,  will  kill  a  dog.  It  forms  a 
permanent  combination  with  the  haemoglobin  of  the  blood,  expelling  oxygen, 
and  producing  insensibility  and  death  by  asphyxia.  Resuscitation  is  rendered 
almost  impossible  by  the  stability  of  the  compound  which  it  forms  with  haemo- 
globin. The  stupefying  energy  of  the  smoke  of  burning  puff-ball  (Lycoperdon 
proteus)  is  due  to  the  presence  of  this  gas. 

Carbonic  Anhydride,  C02,  Carbonic  acid  gas.  Sp.  gr.  of  the  gas,  1.529; 
sp.  gr.  of  the  liquid,  0.83.  Boiling  point,  —78°  C.  (—109°  F.).  A  colorless, 
transparent  gas,  with  a  slightly  acid  taste  and  smell.  It  may  be  liquefied  and 
frozen  by  pressure  and  cold.  It  may  be  liberated  from  any  carbonate  by  the 
action  of  a  stronger  acid.  The  gas  causes  speedy  death  by  asphyxia,  if  inhaled 
without  dilution.  If  it  exceed  three  or  four  per  cent,  of  the  air  that  is 
breathed,  giddiness,  dyspnoea,  muscular  weakness,  and  feeble  and  rapid  move- 
ments of  the  heart  appear.  Any  considerable  increase  of  the  gas  intensifies 
these  phenomena,  and  will  destroy  life,  even  though  a  considerable  amount  of 
air  be  present.  Death  results  partly  through  exclusion  of  oxygen  from  the 
blood,  partly  from  retention  of  carbonic  acid  in  the  blood,  and  partly  from  the 
directly  amesthetico-toxic  action  of  the  substance  upon  the  nervous  tissues. 
A  few  surgeons  have  attempted  to  combine  the  action  of  carbonic  acid  with 
the  vapor  of  ether,  by  causing  the  patient  to  respire  from  a  closed  receiver 
containing  the  vapor,  thus  consuming  his  own  breath  until  rendered  insensible 
by  its  carbonic  acid  mingled  with  ether.  This  practice  cannot  be  too  strongly 
condemned. 

Carbonic  Disulphide,  CS9,  Bisulphide  of  carbon.  Sp.  gr.  1.269.  Boiling 
point,  47°. 7  C.  (117°.8  F.).  A  colorless,  volatile  liquid,  with  a  pungent  aro- 
matic taste,  and  an  agreeable  odor  when  pure.  It  is  formed  by  dropping 
pieces  of  sulphur  upon  red-hot  coals  in  a  retort.  The  general  anaesthetic 
eti'ects  of  the  vapor  resemble  those  produced  by  chloroform,  but  it  also  pro- 
duces great  depression,  sometimes  followed  by  coma.  \Yorkmon  exposed  to 
its  fumes  in  certain  factories  experience  great  depression,  weakness,  and  loss 
of  memory.  The  liquid  has  been  used  externally  with  some  degree  of  success 
for  the  relief  of  neuralgia;  but  the  offensive  odor  if  impurities  are  present, 
and  the  disagreeable  effects  of  the  resulting  vapor,  have  led  to  its  complete 
abandonment. 

Note. — Additional  statistics  show  84  deaths  in  492,235  chloroform  inhalations,  or  one  in  5860. 
(See  p.  423.) 

VOL.  I. — 28 


OPERATIVE  SURGERY  IN  GENERAL. 


BY 


JOHN  H.  BRINTON,  M.D., 


lecturer  on  operative  surgery  in  the  jefferson  medical  college  and  surgeon  to  the 

jefferson  medical  college  hospital,  surgeon  to  the  philadelphia  hospital, 

and  to  st.  Joseph's  hospital,  Philadelphia. 


Submission  to  a  surgical  operation  is  at  all  times,  and  to  every  one,  a  for- 
midable trial.  It  is  not  the  pain  alone  which  affrights,  but  it  is  the  absolute 
self-surrender  from  which  the  patient  shrinks,  conjoined  to  the  uncertainty 
which  attends  the  issue  of  even  the  most  trilling  operation.  An  operation, 
therefore,  should  not  be  lightly  undertaken,  but  should  be  well  considered, 
and  should  only  be  resorted  to  in  the  interests  of  the  patient's  life  or  comfort. 
It  has  been  the  custom  to  speak  of  operative  surgery  as  a  mere  art,  and  its 
achievements  have  been  looked  upon  by  some  as  detrimental  to  the  science 
of  surgery — "  opprobria."  This  is,  however,  but  a  narrow  view,  for  in  the 
adaptation  of  surgical  means  to  the  ends  desired,  in  the  selection  and  prepa- 
ration of  cases,  in  the  operation  itself,  in  the  after-treatment,  in  combating 
all  evil  influences,  and  in  conducting  the  sufferer  to  a  state  of  renewed 
health,  surely  Operative  Surgery  may  justly  share  the  honors  of  the  "Science 
and  the  Art." 


Qualifications  of  a  Surgeon. 

In  all  matters  in  life,  the  every-day  test  of  excellence  is  success.  So,  too, 
the  measure  ot  the  surgeon's  abilities,  in  the  long  run,  is  his  success.  He 
may  be  never  so  brilliant  an  operator,  yet,  lacking  other  essential  qualities,  the 
record  of  his  work  may  be  against  him.  On  the  other  hand,  no  man  can  be 
a  good  surgeon  without  manual  dexterity,  be  his  judgment  and  other  acquire- 
ments what  they  may.  The  qualifications,  therefore,  of  an  operative  surgeon 
appear  to  be  varied  and  comprehensive. 

In  the  first  place,  he  must  be  thoroughly  honest;  he  should  operate  only 
in  the  interests  of  his  patient's  highest  good,  where  life  is  to  be  saved,  or 
discomfort  or  deformity  relieved ;  he  ought  never  to  be  tempted  even  by 
importunity  to  perform  an  unnecessary  operation ;  nor  to  operate  for  the  sake 
of  display,  nor  in  the  desire  of  acquiring  notoriety  or  fame,  nor  for  the  sake 
of  linking  his  name  with  this  or  that  procedure.  In  doubt,  he  should  try 
always  to  place  himself,  as  it  were,  in  the  patient's  place,  and,  before  deciding 
upon  an  operation,  at  all  times  be  able  to  answer  distinctly  and  affirmatively 
the  self-directed  question — Is  the  proposed  surgical  interference  really  for  my 
patient's  good  ? 

(  435  ) 


436  OPERATIVE  SURGERY  IN  GENERAL. 

The  surgeon  should  be  adroit,  and  possessed  of  manual  skill  and  dexterity. 
He  must  be  a  good  workman,  and  his  work  must  be  thorough  and  exact. 
He  should  guard  against  precipitation,  for  in  every  mechanical  art  hasty 
work  means  bad  work ;  and  in  operative  surgery  this  is  sure  to  be  the  case, 
and  it  is  here  that  the  old  motto,  "  festina  lente,"  so  strongly  applies.  A 
hasty  operator  will  often  do  too  much,  and  yet  leave  undone  something 
which  may  affect  the  issue  of  the  case.  Every  operation  must,  therefore,  be 
performed  with  deliberation  and  in  an  orderly  manner.  Each  step  ought  to 
be  well  thought  over  and  planned  beforehand ;  and  whilst  there  must  be  no 
undue  haste,  neither  should  there  be  unnecessary  delay.  The  universal  use 
of  anaesthetics  has  long  since  removed  from  operations  alike  the  necessity  and 
temptation  of  hurry ;  at  the  same  time,  it  has  imposed  upon  the  surgeon  the 
duty  of  quiet,  prompt  procedure,  in  order  that  the  patient  may  be  released 
from  the  anaesthetic  influence  as  soon  as  possible. 

A  knowledge  of  anatomy  is  essential  to  the  operating  surgeon.  By  some  its 
importance  has  been  decried,  and  it  has  been  regarded  as  a  stumbling-block, 
rather  than  an  assistance,  to  the  operator.  For  them,  the  old  maxim  of  "cut 
and  tie  what  bleeds"  has  been  sufficient.  But  at  the  present  day,  in  view  of 
the  frequent  performance  of  operations  of  the  most  delicate  nature,  and  of 
the  invasion  by  the  knife  of  regions  once  sacred  and  undisturbed,  where  the 
only  safeguard  is  the  surgeon's  anatomical  knowledge,  it  is  useless  to  enter 
upon  any  discussion  of  this  subject.  It  may  then  be  assumed,  not  only  that 
the  surgeon  should  possess  a  knowledge  of  anatomy,  but  also  that  this  infor- 
mation must  be  of  a  peculiar  kind.  The  mere  acquaintance  with  muscular 
origin  and  insertion,  with  the  direction  of  vessels  and  nerves,  and  the  like,  is 
insufficient.  The  operating  surgeon  wishes,  and  the  claims  of  his  art  demand, 
more  than  all  this.  His  comprehension  of  anatomy  must  embrace  the  tissues 
in  disease  as  well  as  in  health.  He  must  know  them  topographically,  singly, 
and  in  groups  and  layers,  and  must  be  able  to  recognize  them  when  trans- 
formed by  morbid  action.  An  appreciation  of  tissues  is  in  fact  one  of  the 
very  highest  and  most  practical  of  the  accomplishments  of  the  surgeon,  and 
by  this  is  meant  the  power  to  recognize  the  living  tissues  under  all  circum- 
stances. 

It  seems,  in  truth,  as  if  there  were  two  varieties  of  anatomical  knowledge : 
the  knowledge  of  the  anatomy  of  the  dead  subject — cadaveric  anatomy — as 
scon  by  the  pure  anatomist ;  this  is  well  enough  in  its  way,  and  answers 
sufficiently  as  a  basis  for  the  other,  to  wit,  a  knowledge  of  clinical  anatomy, 
which  alone  can  serve  the  purposes  of  the  surgeon — the  anatomy  of  the  living 
tissues.  It  is  only  this  knowledge  of  applied  anatomy  which  confers  upon 
the  educated  and  practised  operator  that  skill  which  leads  up  to  great  suc- 
cesses. It  is  this  alone  that  enables  him  to  recognize  tissues, however  masked, 
or  changed,  or  hidden.  It  is  this  which  gives  his  hand  dexterity,  and  almost 
endows  his  knite  with  vital  consciousness.  Without  this  power  of  discrimi- 
nating tissues,  tin;  operations  of  the  surgeon  must  be  at  best  gropings  in  the 
dark  ;  with  it,  on  the  other  hand,  they  will  be  characterized  by  skill  and 
certainty,  by  safety  for  his  patient,  and  by  satisfaction  for  himself.  The 
acquisition  of  this  knowledge  of  anatomy  is  no  easy  matter ;  it  cannot  be 
gathered  from  books,  nor  can  it  be  arrived  at  to  best  advantage  by  the  ordi- 
nary methods  of  dissection.  It  can  only  be  learned  by  dissections  practised 
by  regions,  and  with  a  true  surgical  intent,  and  these  must  be  repeated  again 
and  again  ;  for,  as  Pare  tells  us  in  his  chapter  on  " Chirurgicall  Operations," 
"Thou  shall  far  more  easily  and  happily  attain  to  the  knowledg  of  these  things 
by  long  use  and  much  exercise,  than  by  much  reading  of  Books,  or  daily  hear- 
ing of  Teachers.      For  speech,  how  perspicuous  and  elegant  soever  it  be, 


QUALIFICATIONS   OF   A   SURGEON.  437 

cannot  so  vively  express  anything, -as  that  which  is  subjected  to  the  faithfull 
eyes  and  hands."1  This  knowledge,  once  acquired,  must  lie  kept  up  by  dis- 
sections repeated  from  time  to  time,  and  especially  ought  the  surgeon  to 
refresh  his  memory  when  about  to  venture  upon  any  new  or  delicate  pro- 
cedure. Many  blunders  happen  during  an  operation  from  a  defective  ac- 
quaintance with  anatomy;  none  because  the  operator  knows  too  much.  Re- 
peated practice  upon  the  cadaver  cannot  be  too  heartily  enjoined  ;  and  this 
will  at  all  times  prove  of  advantage  to  the  surgeon,  whatever  his  years  may 
be,  and  however  ripe  his  experience. 

The  demeanor  of  the  surgeon  is  a  matter  of  no  little  importance.  On  the 
eve  of  operation,  his  every  look  and  movement  are  closely  watched,  and  a 
patient  will  often  derive  much  comfort  from  noting  the  composure  of  the 
surgeon,  his  coolness  and  evident  self-reliance.  In  his  manner  he  should  be 
kind  and  sympathizing,  dignified,  and  free  from  ill-placed  levity.  Above  all 
things  let  him  try  to  foster  in  his  patient  that  faith  and  confidence  in  him, 
which  go  so  far  to  soothe  the  spirit  and  strengthen  the  resolution  of  one  about 
to  place  himself  in  the  surgeon's  hands.  It  is  not,  however,  alone  upon  the 
patient  and  his  friends,  that  the  happy  effect  of  the  surgeon's  mental  composure 
is  produced.  It  intiuences  too  his  assistants  and  the  lookers-on  at  the  operation  ; 
and  these  are  sometimes  many,  for  the  work  of  the  operator  is  often  done  in 
public,  where  he  stands  in  full  view  of  critical  eyes,  and  not  unfrequently 
exposed  to  carping  tongues.  The  surgeon  ought  not  to  present  a  mere  out- 
ward composure  ;  but  in  reality  he  should  possess  it.  Sangfroid,  intrepidity, 
and  the  power  of  self-support  are  absolutely  essential  to  his  success.  His 
presence  of  mind  should  never  desert  him.  He  must  train  himself  to  think, 
during  operation,  of  his  work,  and  of  his  patient;  and  not  of  the  bystanders. 
If  things  go  wrong,  he  must  preserve  his  coolness,  and  not  suffer  himself  to  fall 
into  that  condition  of  mind  which  has  been  described  as  "  surgical  deli- 
rium"— in  which  the  operator  loses  his  head,  and  strives  to  extricate  him- 
self from  embarrassment  by  ill-directed  and  often  aimless  efforts. 

For  it  must  be  here  observed  that,  while  the  surgeon  may,  year  after  year, 
pass  along  with  little  seriously  amiss  in  his  operative  practice,  yet,  sooner  or 
later,  trouble  and  accident  may,  and  indeed  must,  come.  Startling  vicissi- 
tudes, catastrophes  which  can  neither  be  anticipated  nor  prevented,  are  sure 
to  happen.  These  are  the  incidents  of  human  life,  and  the  professional  man 
who  deals  so  largely  with  life  itself  cannot  expect  to  escape  them.  It  is  im- 
possible to  conduct  an  active  surgical  practice  for  a  long  period  without  meet- 
ing with  occurrences  which  Paget  has  justly  called  "  surgical  calamities ;" 
with  every  care  it  is  not  possible  to  foresee  such  contingencies,  and  the  sur- 
geon must  stand  prepared  to  meet  them  as  they  come.  Let  him  then  train 
himself  in  habits  of  independent  thought,  action,  and  self-reliance.  Let  him 
stand  strong  in  the  best  knowledge  of  his  profession,  and  in  the  firm  determi- 
nation to  act  for  his  patients'  good, and  for  that  alone;  then,  if  ever  these 
dreaded  calamities  shall  fall  upon  him,  his  shoulders  will  prove  strong  enough 
to  bear  them. 

The  success  of  the  operation  is  undoubtedly  influenced  by  manual  dexterity 
in  its  performance,  but  beyond  the  mere  mechanical  skill  are  other  factors. 
The  proper  selection  of  cases,  Awe  preparation  for  the  operation,  and  careful  nurs- 
ing, feeding,  and  after-treatment,  have  very  much  to  do  with  the  welfare  of  the 
patient.     Indeed  it  may  be  said  that  the  exercise  of  a  wise  and  sound  judg- 

The  works  of  that  famous  cliirurgeon  Ambrose  Parey,  translated  out  of  Latin,  and  compared 
with  the  French  by  Th.  Johnson.     Book  I.,  Chap.  II.     London,  1049. 


438  OPERATIVE   SURGERY   IN   GENERAL. 

ment,  in  these  respects,  bears  greatly  upon  ultimate  success  or  failure.  It  is 
the  observance  and  enforcement  of  all  precautions,  before,  during,  and  after 
an  operation,  which  give  the  sufferer  his  best  chances,  and  it  must  never  lie 
forgotten  that  the  latter  is  entitled  to  all  the  chances  which  operative  skill 
and  the  exercise  of  sound  judgment  can  possibly  afford.  It  is  a  mistake  to 
look  upon  the  failure  of  an  operation  simply  as  an  untoward  accident  to  the 
operator ;  we  must  recollect  that  there  is  another  party  to  the  transaction, 
the  patient ;  and  if  harm  befall  him,  either  from  deficient  skill,  lack  of  pru- 
dence, or  too  biased  convictions  on  the  part  of  his  surgical  attendant,  surely 
there  is  matter  of  self-reproach  for  him  in  whom  he  trusted.  If,  on  the 
other  hand,  the  surgeon  acts  on  full  consideration  of  the  facts  attending  each 
individual  case,  with  a  wide  knowledge  of  the  general  practice  of  others, 
with  proper  reliance  on  his  own  experience,  and  an  earnest  seeking  after  his 
patient's  good  ;  then  indeed  he  has  done  all  that  man  can  do,  and  may  humbly 
await  the  issue  from  the  hands  of  the  Almighty  Arbiter  of  all  things  human. 

While  it  is  incumbent  upon  the  surgeon  to  do  much  that  is  merely  mani- 
pulative in  character,  it  must  not  be  forgotten  that,  besides  the  operation,  he 
must  perform  many  duties  which  demand  the  exercise  of  the  highest  func- 
tions of  the  medical  mind.  He  must  be  a  good  diagnostician,  medical  as  well 
as  surgical,  and  possess  an  accurate  knowledge  of  morbid  anatomy,  and  of 
general  pathology.  He  must,  above  all  things,  exercise  skill  in  searching 
for,  and  in  detecting,  visceral  disease,  for  here  a  broad  field  has  been  opened 
to  the  view  of  the  practical  surgeon.  In  times  past,  it  was  perhaps  too  much 
his  custom  to  confine  his  study  to  that  only  which  was  evident  to  the  eyes 
and  touch.  He  did  not  trouble  himself  greatly  with  those  morbid  processes 
which  were  developing  in  organs,  it  might  be  somewhat  removed  from  the 
local  seat  of  disease,  but  which  were  often  related  to  or  influenced  by  the 
proposed  operation.  Pathology  has,  however,  made  fast  onward  strides,  and 
no  operation  can  now  be  undertaken  without  a  careful  examination  of  the 
internal  organs ;  since  the  presence  of  lurking  visceral  disease,  often  unsus- 
pected, may  forbid  or  modify  surgical  interference.  The  surgeon  must  more- 
over be  a  good  therapeutist,  and  an  expert  clinical  observer — ever  prompt  to 
catch  the  passing  indication,  ever  ready  to  interfere  on  just  occasion,  or,  with 
wise  caution,  patient  to  hold  his  hand.  He  should  be  sharp-witted  in  emer- 
gencies, and  quick  in  his  decisions ;  for  the  tide  of  surgical  accident  runs 
fast,  and  if  he  falter  or  delay,  precious  moments  may  be  forever  lost.  In 
short,  the  surgeon  should  be  an  Accomplished  Physician  as  well  as  a  Skilful 
Operator,  possessing  a  comprehensive  knowledge  of  diagnosis,  pathology,  and 
therapeutics  ;  with  less  he  can  neither  do  justice  to  his  patient,  nor  satisfy 
the  demands  of  his  own  conscience. 


Preparation  for  an  Operation. 

A  certain  amount  of  risk  to  life  accompanies  all  surgical  interference.  It 
is  present  in  a  marked  degree  in  serious  operations,  and  is  not  absent  from 
those  of  apparently  the  most  trifling  character.  Death  may  and  has  followed 
the  simple  introduction  of  a  sound,  the  slitting  of  a  contracted  meatus,  or 
the  ligation  of  an  apparently  insignificant  pile.  It  is,  therefore,  fit  that  the 
surgeon  before  operating  should  bear  in  mind  the  possibility  of  an  untoward 
result,  and  that  lie  should  seek  by  every  means  in  his  power  to  guard  his 
patient  against  unfavorable  chances.  1 1  is  wisdom  and  judgment  will  be 
never  more  apparent  than  in  the  care  and  skill  he  may  exercise  in  preparing 
the  patient  tor  operation.     Each  case  should  be  to  him  a  study,  and  he  ought 


PREPARATION   FOR   AN   OPERATION.  439 

carefully  to  investigate  its  characters.  His  conclusions  should  be  deliberately 
arrived  at,  and  the  propriety  of  an  operation  must  be  quite  clear  to  his  own 
mind,  before  any  announcement  is  made  of  its  necessity.  "When,  however, 
it  is  evident  to  the  surgeon  that  an  operation  should  be  done,  it  becomes  his 
duty  to  state  the  facts  to  the  patient,  if  he  is  of  sufficient  age,  and  in  a  pro- 
per state  of  mind,  or,  if  not,  to  his  family  or  friends.  This  should  be  done 
gently,  and  not  abruptly,  nor  in  a  manner  calculated  to  alarm.  The  necessity 
of  the  operation  ought  to  be  clearly  explained  to  those  concerned,  and  the 
chances  of  success  and  recovery  fairly  laid  before  them. 

It  is  also  right  that  the  surgeon  should  add  to  these  statements  the  weight 
of  his  professional  opinion,  and  he  must  not  shrink  from  the  responsibility 
of  so  doing,  nor  speak  with  hesitation  or  doubt.  He  must  remember  that  the 
persons  interested  look  to  him  for  advice,  and  that  as  consultants  they  are 
fairly  entitled  to  whatever  help  he  can  so  render  them.  It  is  not  to  be  ex- 
pected that  the  public  can  always  decide  wisely  in  matters  affecting  life 
or  health;  they  must  in  the  end  depend  upon  professional  judgment ;  aud  the 
professional  utterance  ought  to  be  positive  and  unmistakable.  It  becomes, 
therefore,  the  duty  of  the  surgeon  to  neither  exaggerate  nor  underrate  the 
possible  peril  of  an  operation  ;  he  must  think  for  his  patient,  and  by  his  sym- 
pathy and  the  kindness  of  his  manner  win  the  confidence  of  the  latter,  so 
making  him  to  feel  that  the  arm  of  his  surgical  adviser  is  in  truth  one  of 
strength,  upon  which  he,  in  his  own  weakness,  may  safely  lean.  All  this  the 
surgeon  may  rightly  do,  not  endangering  his  professional  position,  but  rather 
strengthening  it  by  his  services  as  counsellor  and  friend.  To  the  question 
which  is  so  often  put  in  minor  cases,  "Is  there  any  danger  in  the  operation?" 
he  can  truthfully  answer,  "  Xot  greater  than  in  the  chapter  of  the  ordinary 
accidents  of  life,  and  whatever  risk  there  is,  I  advise  you  to  take  it."  The 
ultimate  decision  thus  rests  with  the  patient  himself,  but  he  may  be  fortified 
in  mind,  and  upheld  in  a  correct  judgment,  by  the  judicious  and  wise  words 
of  his  professional  attendant. 

In  a  general  way,  it  is  customary  to  divide  surgical  operations  into  two 
great  classes.  The  first  comprises  operations  of  necessity,  where  life  is  at  stake, 
and  where  surgical  interference  to  be  of  avail  must  be  immediate.  Ope- 
rations for  strangulated  hernia,  or  for  hemorrhage,  or  for  foreign  bodies  in 
the  air  passages,  or  for  many  surgical  injuries,  are  examples  of  this  nature. 
The  second  class  comprises  operations  of  expediency,  in  which  a  slight  delay  in 
performance  does  not  materially  atfect  the  result.  The  removal  of  morbid 
growths,  the  correction  of  deformities,  and  many  other  operations  in  the 
great  category  of  surgical  diseases,  are  examples  of  the  second  order.  In  de- 
ciding upon  operations  of  the  first  class,  the  surgeon  must  often  assume  a 
great  responsibility.  His  professional  duty  demands  that  he  should  act  deci- 
sively and  promptly  to  save  life ;  and,  in  the  absence  of  friends,  or  where  the 
patient  is  very  young,  or  from  the  very  nature  of  the  case  incapable  of  being 
consulted,  the  surgical  attendant  must  take  the  burden  upon  his  own  shoul- 
ders. Sometimes,  in  such  capital  cases,  the  advice  of  colleagues  may  be 
obtained,  but  where  the  urgency  is  very  great,  the  surgeon  shoald  learn  to 
depend  fearlessly  upon  his  own  judgment,  and  to  act  in  accordance  with  it. 

Time  for  Operation. — In  ordinary  cases, not  those  of  immediate  necessity, 
where  an  operation  has  been  decided  upon,  the  first  question  which  presents 
itself  to  the  mind  is  the  time  for  its  performance.  Broadly  stated,  the  answer 
to  this  question  is,  "As  soon  as  the  patient  can  be  brought  into  the  best  state 
of  mind  and  body."  The  first  of  these  conditions  must  depend  somewhat 
upon  the  patient's  morale  and  his  confidence  in  his  surgeon.     Many  sufferers 


440  OPERATIVE    SURGERY   IN   GENERAL. 

are  nervous  and  timid ;  they  dread  the  future,  and  shudder  at  the  thought  of 
an  operation.  Delay  in  these  cases  often  makes  matters  worse ;  the  mind  re- 
acts upon  the  body  ;  and,  for  them,  the  sooner  an  operation  can  be  performed 
with  safety  the  better.  Other  patients  may  be  less  fearful  of  results,  and  may 
seem  to  be  stoical,  almost  indifferent.  These  not  unfrequently  ask  time  for 
consideration,  and,  having  reflected,  come  calmly  to  a  decision,  and  place 
themselves  in  the  hands  of  the  surgeon  with  quiet  confidence  and  bravery. 

Preparation  of  Patient. — The  general  bodily  health  of  one  who  is  to 
undergo  an  operation  must  always  be  most  carefully  looked  to,  and  all  pre- 
cautions taken  to  bring  it  into  the  best  possible  condition.  Every  operation, 
no  matter  how  slight  it  may  be,  presupposes  some  extra  strain  upon  the  con- 
stitutional powers,  and  the  resources  of  our  art  should  be  taxed  to  meet  this 
demand.  Unfortunately,  it  often  happens  that  the  very  occasion  for  surgical 
interference  is  in  itself  a  cause  of  impairment  of  vital  strength,  and  unneces- 
sary delay  in  operation  is  therefore  to  be  deprecated.  In  hospital  practice 
this  is  especially  the  case.  Patients*  enter  the  wards  with  impaired  nutrition, 
enfeebled  by  pain  and  suffering,  and  exhausted  by  chronic  suppuration.  The 
effort  to  improve  their  general  state  seems  to  be  a  laudable  one ;  but  even 
here  mistakes  may  be  committed ;  for  it  is  undoubtedly  true  that  too  pro- 
longed a  residence  in  hospital  is  often  productive  of  injury  rather  than  of 
benefit  to  the  patient.  For  the  first  week  or  ten  days,  he  may  seem  to  im- 
prove, but  it  is  a  matter  of  common  experience  that  after  that  period  much 
change  for  the  better  is,  as  a  rule,  scarcely  to  be  looked  for.  It  would  seem 
therefore  wise,  in  such  cases,  not  to  defer  unduly  an  inevitable  operation,  but 
to  proceed  to  its  performance,  in  the  absence  of  positive  contra-indications,  as 
soon  as  the  secretions  have  been  brought  into  tolerable  condition.  The  re- 
moval of  a  source  of  irritation,  or  of  a  drain  upon  the  constitution,  will  often 
do  more  to  bring  up  a  patient  than  any  prolonged  course  either  of  dietetics  or 
of  therapeutics,"and  that  this  is  true,  is  amply  shown  by  the  success  which 
proverbially  follows  secondary  operations. 

Rest. — The  influence  of  rest  of  mind  and  body,  in  fitting  the  latter  to  pass 
safely  through  the  perils  of  an  operation,  must  not  be  overlooked.  The  quiet 
of  a  day  or  so  in  bed  permits  the  patient  to  recover  from  the  fatigues  of  his 
daily  work,  and  to  obtain  that  necessary  sleep  which  has  sometimes  been  cur- 
tailed by  the  exigencies  of  labor.  Overworked  organs,  and  notably  the  heart, 
pass  into  a  condition  of  repose ;  excited  or  perverted  functions  are  soothed  or 
corrected ;  local  congestions  are  relieved ;  and,  in  short,  body  and  mind  are  alike 
benefited  by  the  state  of  true  physiological  rest  thus  brought  about.  Pain, 
which  may  have  been  aggravated  by  locomotion,  becomes  less,  or  disappears  : 
and  the  patient  acquires  that  custom  or  ability  to  remain  tranquilly  in  bed 
which  may  become  essential  to  his  future  welfare.  Nothing  is  more  detri- 
mental to  the  success  of  an  operation  than  after-restlessness  and  jactitation, 
and  the  exercise  of  patience,  and  practice  in  remaining  still  in  bed,  is  a  matter 
of  more  importance  than  it  is  usually  considered.  During  this  period  of  rest, 
too,  the  medical  attendant  has  ample  opportunity  for  familiarizing  himself 
with  his  patient,  and  for  acquiring  that  knowledge  of  him  which  may  have  a 
direct  bearing  on  the  after-treatment.  lie  is  enabled  also  to  judge  of  his  con- 
stitutional condition,  byrepeated  physical  examinations, and  to  form  thatcor- 
iv.  t  estimate  of  his  strength  or  weakness  which  may  prove  of  so  much  value 
in  the  future  conduct  of  the  case.  It  is  a  matter  of  everyday  observation  that 
where  operations  arc  hurriedly  undertaken,  without  due  investigation  of  the 
patient's  condition,  they  are  apt  to  be  attended  by  perils  which  might  have 
been  avoided  by  more  careful  examination.     The  writer  can  recall  case  upon 


ANESTHESIA.  441 

case,  where  the  happy  results  of  serious  operations  have  heen  attributed  to 
mere  skill  at  the  time  of  performance,  when  in  truth  they  were  not  a  little 
due  to  the  previous  painstaking  and  repeated  examinations  of  the  patient, 
and  to  the  careful  and  watchful  study  of  his  idiosyncrasies. 

Preliminary  Treatment. — Deferring  for  a  moment  the  subjects  of  the  risks 
of  operations,  and  the  causes  influencing  their  results,  it  ma}7  be  well  to  inquire 
what  preliminary  steps  must  be  taken  to  put  the  patient  in  the  best  condition 
for  the  operation,  when  the  latter  is  imperative,  or  when  it  has  been  decided 
upon  as  judicious.  If  the  operation  be  one  of  emergency,  such  as  herniotomy,  or 
tracheotomy  for  urgent  cause,  preparation  in  a  general  way  can  scarcely  be 
attempted.  The  surgeon  must  do  his  best  to  save  life  already  endangered, 
and  the  patient  must  take  his  chances,  such  as  they  are.  On  the  other  hand, 
if  the  case  be  one  of  a  chronic  nature,  certain  useful  precautions  before  opera- 
tion may  be  attempted.  If  the  patient  is  in  poor  condition,  and  if  time  admits, 
the  requisite  diet,  stimulus,  and  tonics  may  be  employed,  and  the  rest  already 
referred  to  enjoined.  The  secretions  may  be  attended  to,  and  the  bowels  regu- 
lated as  demanded.  All  previous  medication,  which  may  be  inappropriate  to 
the  time  of  operation,  should  be  stopped  ;  and  a  sufficient  interval  allowed 
for  the  elimination  from  the  system  of  such  drugs  as  digitalis,  arsenic,  the 
iodide  of  potassium,  and  the  like.  If  the  case  is  one  of  injury  demanding 
amputation,  and  the  patient  has  not  yet  reacted,  the  bleeding  should  be  con- 
trolled, and  such  stimulus  administered  as  will  bring  about  reaction,  and  re- 
lease the  sufferer  from  the  state  of  shock. 

The  advisability  of  administering  stimulus  just  before  operation  is  a  ques- 
tion which  has  been  much  discussed,  and  on  which  different  opinions  are  now 
entertained.  By  some,  a  parallelism  has  been  affirmed  between  the  effects  of 
alcoholic  stimulus  and  those  of  the  anesthetic,  especially  sulphuric  ether; 
both  being  regarded  as  agents  which  secondarily  depress  the  action  of 
the  heart.  Yet  it  is  probable  that  the  great  majority  of  practical  surgeons 
look  favorably  upon  the  administration  of  whiskey  a  short  time  prior  to 
operation,  especially  if  with  the  stimulus  a  small  amount  of  opium  is  ad- 
ministered, either  by  the  mouth  or  hypodermically.  Clinically  speaking, 
this  conjoined  exhibition  of  alcohol  and  opium  is  probably  judicious,  since 
it  would  seem  to  exercise  a  triple  influence :  In  the  first  place  it  appears  to 
lessen  the  shock  of  operation  ;  in  the  second  it  tranquillizes  the  patient  after 
the  operation,  and  prevents  or  soothes  the  subsequent  pain  ;  and  in  the  third 
place  it  expedites  anaesthesia,  and  lessens  the  amount  of  ether  necessary  to  be 
given.  The  testimony  of  many  excellent  surgeons  seems  to  be  conclusive  in 
this  direction,  and  in  such  a  matter  mere  theoretical  opinions  cannot  have 
weight  when  opposed  to  the  direct  results  of  clinical  experience.  In  admin- 
istering stimulus,  care  should  be  taken  to  give  it  three-quarters  of  an  hour  or 
an  hour  before  operation.  If  given  later  than  this,  it  may  cause  nausea  and 
vomiting  as  the  inhalation  of  the  anesthetic  progresses— always  an  annoying 
complication,  and  peculiarly  so  at  the  beginning  of  an  operation. 


Anaesthesia. 

It  would  be  out  of  place  in  this  article  to  enter  upon  the  history  of  surgical 
anesthesia,  or  to  discuss  the  priority  of  claim  of  those  with  whom  it  origi- 
nated. It  is  sufficient  to  say  that  its  discovery  originated  in  Hartford,  Con- 
necticut, in  1844,  and  that  its  first  practical  application  for  surgical  purposes 
was  made  in  Boston  about  the  year  1846 — the  agent  then  employed  being  sul- 
phuric ether.     In  the  following  year  the  anesthetic  qualities  of  chloroform 


442  OPERATIVE   SURGERY   IN   GENERAL. 

were  announced  by  Professor  Simpson,  of  Edinburgh.  Since  that  time,  the 
value  of  these  two  agents  has  been  universally  recognized.  Throughout 
Europe,  until  quite  recently,  chloroform  has  been  preferred  by  surgeons*; 
while  in  America  the  professional  mind  has  been  greatly  divided  as  to  the 
relative  value  of  the  two  agents.  In  the  northern  portion  of  the  country, 
ether  is  probably  the  favorite  agent,  while  in  the  south  and  west  the  predi- 
lection is  in  favor  of  chloroform.  The  merits  of  the  rival  agents  may  be 
thus  briefly  summed  up :  Both  produce  complete  anesthesia,  but  ether  is  un- 
doubtedly the  safer  agent.  It  is,  however,  far  more  bulky,  and  consequently 
more  difficult  of  transportation.  It  is,  therefore,  not  so  well  adapted  as  chlo- 
roform for  use  in  military  or  country  practice.  It  is  slower  in  its  action,  and 
more  disagreeable  than  chloroform ;  and  its  use  is  attended  by  more  strug- 
gling and  rebellion  on  the  part  of  the  patient.  The  stimulating  action  of  ether 
is  felt  largely  by  the  nervous  and  respiratory  systems,  and  on  the  latter  it 
sometimes  produces  much  irritation.  The  action  of  the  heart  is  also  stimu- 
lated by  ether,  and  in  this  respect  it  differs  from  chloroform,  which  is  apt  to 
cause  cardiac  sedation.  It  seems,  therefore,  that  the  use  of  ether  as  an  anaes- 
thetic is  indicated  in  cases  attended  by  nervous  shock,  and  also  where  there 
is  cardiac  weakness,  the  result  of  fatty  changes  or  of  ventricular  dilatation. 

Comparison  of  Ether  with  Chloroform. — The  primary  excitant  effects 
of  ether  are  shortly  followed  by  secondary  sedation.  This  is  at  times  aggra- 
vated by  the  tendency  to  nausea  and  vomiting,  which  occasionally  is  persist- 
ent, and  which  it  is  not  always  easy  to  check.  Chloroform,  on  the  other  hand, 
is  free  from  most  of  these  objections.  Its  odor  is  agreeable,  and  its  first  effects 
sedative  ;  it  acts  promptly,  and,  as  a  rule,  without  causing  that  degree  of 
excitation  and  muscular  action  which  is  so  characteristic  of  ether.  It  proba- 
bably  causes  less  nausea  and  gastric  irritation,  and  it  acts  kindly  and  safely 
upon  children.  The  great  matter,  however,  in  the  choice  of  an  anaesthetic  is 
that  of  safety,  and  the  one  question  to  be  answered  is  simply  this  :  Which 
carries  with  it  the  least  peril  to  the  life  of  the  patient,  ether  or  chloroform  ? — 
and  here  it  must  be  stated  that  the  condition  of  anaesthesia  is  always  one  of 
some  danger,  and  that  no  anaesthetic  is  altogether  safe.  A  patient  in  a  con- 
dition of  absolute  anaesthetic  unconsciousness,  is  necessarily  in  more  or  less 
jeopardy  of  life,  and  it  is  incumbent  upon  the  operating  surgeon  never  to 
lose  sight  of  this  fact.  It  is  to  be  feared  that  the  comparative  impunity 
which  has  attended  the  long-continued  use  of  anaesthetics,  tends  to  beget  in 
the  mind  of  the  surgeon  too  great  a  confidence  in  their  safety,  and  that  he 
sometimes  realizes  only  when  it  is  too  late  that  this  blind  confidence  may  be 
unfounded.  Especially  is  this  the  case  when  the  exhibition  of  the  anaesthetic 
is  submitted  to  unskilled  hands,  and  that  this  is  very  often  done  it  is  impos- 
sible to  deny.  In  reality,  the  assistant  who  has  charge  of  the  ether  or  chloro- 
form, plays  a  part  in  the  operation  scarcely  secondary  to  that  of  the  surgeon 
himself,  for  on  his  skill,  watchfulness,  and  judgment,  the  welfare  of  the  pa- 
tient to  a  great  extend  depends.  It  is,  therefore,  incumbent  upon  the  operator 
to  devolve  this  important  duty  only  upon  one  who  is  qualified  to  undertake 
it ;  and  the  assistant  himself  must  devote  his  whole  mind  to  this  given  task. 
lie  ought  to  do  nothing  else,  and  should  not  permit  his  attention  to  wander 
for  a  moment  from  the  patient  before  him,  nor  attempt  to  render  any  other 
assistance  in  the  operation  than  that  to  which  he  is  particularly  assigned. 
He  must  carefully  watch  the  breathing  of  the  patient,  and  moderate  or  sus- 
pend  the  anaesthetic  on  the  slightest  evidence  of  its  irregularity.  He  should 
be  on  the  watch  against  retraction  of  the  tongue,  and,  if  this  happens,  he  must 
blatantly  draw  it  forward  with  a  hook  or  forceps,  and  see  to  the  removal  of 
mucus  from  the  mouth  or  fauces.     Not  unfrequently,  spasm  and  closure  of 


ADMINISTRATION    OF    ETHER.  443 

the  larynx  occur,  evinced  by  the  lividity  and  discoloration  of  the  lips  and 
ears.  This  can  usually  be  relieved  by  turning  the  head,  or  by  pushing  for- 
wards the  angles  of  the  jaws,  and  by  making  pressure  upon  the  chest,  thus 
exciting  afresh  the  respiratory  efforts.  The  pulse  must  be  watched  as  well 
as  the  breathing,  especially  if  the  patient  have  a  fatty  heart,  or  any  other 
form  of  organic  cardiac  disease. 

While,  in  the  great  majority  of  cases,  ether  will  accomplish  all  that  chlo- 
roform can  do,  and  indeed  all  that  can  be  desired,  and,  as  we  think,  with  a 
greater  degree  of  safety,  there  are  nevertheless  instances  in  which  it  seems 
proper  to  employ  chloroform,.  As  is  well  known,  ether  vapor  acts  as  an 
irritant  to  the  lungs  even  when  healthy,  and  its  use  is  sometimes  followed  by 
more  or  less  bronchitis.  It  should  not,  therefore,  be  resorted  to  when  any 
pulmonary  irritation  or  inflammation  already  exists,  but  preference  should 
be  given  to  chloroform.  Acute  oedema  of  the  lungs,  terminating  fatally  in  a 
few  hours,  has  occurred  after,  the  inhalation  of  ether  to  the  writer's  knowledge, 
and  it  is  probable  that  most  of  the  few  deaths  charged  to  the  use  of  ether 
have  in  reality  been  due  to  this  cause.  An  examination  of  the  lungs  and  of 
the  heart  must  consequently  be  made  before  ether  is  given.  The  use  of  ether 
in  cardiac  disease  has  also  been  questioned,  but  here  hesitation  need  only  be 
felt  when  there  is  a  tendency  to  overloading  of  the  right  heart ;  and  there 
does  not  appear  to  be  any  reason  for  not  giving  ether  when  the  heart  is  weak 
or  tatty.  Indeed,  its  action  as  a  cardiac  stimulant  would  rather  favor  its 
employment  in  these  cases,  but  under  such  circumstances  its  effects  must  of 
course  be  carefully  watched.  Chloroform  is  peculiarly  adapted  for  children ; 
upon  them  it  acts  readily,  and,  as  far  as  is  known,  safely. 

First  Insensibility  from  Ether. — Before  describing  the  mode  of  adminis- 
tration of  ether  and  chloroform,  it  may  be  well  to  allude  here  to  one  of  the 
effects  of  ether  inhalation  which  is  not  as  widely  known  as  it  deserves  to  be 
namely,  the  transitory  state  of  first  insensibility  produced  by  a  few  whiffs  of 
ether,  originally  pointed  out  by  Dr.  Packard,  of  Philadelphia,1  who  has 
noticed  that,  if,  when  a  patient  begins  to  inhale  ether, 

"  •  •  •  •  lie  be  told  to  hold  up  his  hand,  and  the  direction  be  repeated  as  often  as 
necessary,  for  a  little  while  he  will  obey,  but  soon  there  will  be  a  failure  of  voluntary 

power,  and  the  hand  will  drop.     At  this  instant  there  begins  a  very  brief  period less 

than  a  minute — of  total  insensibility.  If  the  inhalation  be  now  suspended,  conscious- 
ness will  return  at  once,  and  the  patient  will  come  to  himself  without  headache,  nausea, 
or  any  other  of  the  disagreeable  effects  so  commonly  experienced  after  the  prolonged 
administration  of  the  anaesthetic.  During  this  brief  period  of  ana3sthesia,  the  'first 
insensibility,'  as  I  have  called  it,  any  operation  may  be  performed  as  painlessly  as  if 

the  inhalation  had  been  carried  to  the  fullest  extent I  feel  warranted  in 

asserting  that  this  first  insensibility  invariably  occurs  ;  that  it  is  absolute  and  profound, 
though  brief;  and  that  it  may  always  be  detected  and  taken  advantage  of  by  careful 
observation  and  prompt  action." 

From  a  personal  experience,  the  writer  can  testify  to  the  entire  accuracy 
of  Dr.  Packard's  statements,  not  only  as  to  the  occurrence  of  this  short  in- 
sensibility, but  also  as  to  its  thoroughness  and  completeness  as  regards  any 
sensation  of  pain  from  cutting  operations. 

Administration  of  Ether. — In  obtaining  anesthesia  from  ether,  not  a 
little  depends  upon  the  skill  of  the  administrator.  If  the  patient  be  frightened 
or  roughly  handled,  he  naturally  rebels,  and  the  process  is  necessarily  pro- 
longed, and  therefore  to  a  degree  imperfect.     Here,  as  in  all  other  surgical 

1  American  Journal  of  the  Medical  Sciences,  July,  1877,  and  April,  1878. 


444  OPERATIVE    SURGERY    IN   GENERAL. 

procedures,  the  first  step  should  he  to  win  the  confidence  of  the  patient,  and 
to  impress  him  by  gentleness  rather  than  by  force.  In  the  early  days  of 
ether,  various  complicated  forms  of  apparatus  and  mouth-pieces  were  con- 
structed to  assist  the  inhalation.  In  America  these  have  given  way  to 
methods  of  greater  simplicity — the  employment  of  the  folded  towel  or  the 
sponge.  Perhaps  the  simplest  plan  is  the  use  of  a  towel  folded  and  pinned 
in  the  shape  of  a  cone  ;  the  sides  of  the  cone  may  be  stiflt'ened  by  placing 
within  the  folds  of  the  towel  a  layer  or  two  of  newspaper.  A  chamber  is 
thus  formed  for  the  retention  of  the  ether  vapor,  the  base  of  the  cone  being 
sufficiently  large  to  thoroughly  cover  the  mouth  and  nostrils,  and  to  include 
the  lower  jaw.  The  eyes  of  the  patient  should  be  covered  with  a  light  nap- 
kin or  handkerchief  at  the  beginning  of  the  inhalation.  This  precaution 
shuts  out  the  observation  of  external  circumstances,  and  has  a  very  marked 
effect  in  hastening  the  period  of  insensibility.  It  is  well  also  to  divert  the 
attention  of  the  patient  by  directing  him  to  count  slowly  "one,  two,  three,"  and 
so  on,  following  the  lead  of  the  administrator.  The  expiratory  effort  thus 
induced  is  followed  by  a  corresponding  inspiration,  and  full  inhalation  of  the 
ether  is  thus  greatly  favored.  Few  persons  can  count  as  high  as  twenty-five 
or  thirty  without  feeling  the  effect  of  the  agent,  and  scarcely  any  can  reach 
sixty  or  seventy  without  becoming  unconscious.  The  best  test  of  the  proper 
period  for  operation  having  arrived  is  insensibility  of  the  eyeball  and  general 
muscular  relaxation.  The  ether  can  then  be  withheld  or  pushed,  as  the  cir- 
cumstances of  the  case  may  indicate.  The  unconscious  occupation  of  the 
mind  by  the  counting  method  will  be  found  preferable  to  the  usual  coaxing 
attempts,  or  the  futile  advice  to  the  patient  that  he  should  try  and  go  to 
sleep,  which  is  commonly  under  the  circumstances  very  .difficult  for  him  to 
accomplish.  Ether  can  also  be  administered  from  the  folds  of  a  towrel  with- 
out the  formation  of  the  cone  described.  This  is  not  so  perfect  a  method, 
lacking,  as  it  does,  the  formation  of  a  true  ether  atmosphere,  and  is  accom- 
panied by  more  resistance  and  struggling  of  the  patient;  nor  does  it  seem  to 
possess  any  of  the  advantages  of  the  method  already  described. 

When  the  patient  is  inclined  to  resist,  or  takes  ether  badly,  the  resistance 
can  usually  be  overcome,  if  the  exhibition  of  the  vapor  be  begun  slowly,  and  if 
the  cone,  towel,  or  other  vehicle,  be  gradually  brought  nearer  to  the  face,  as  he 
becomes  accustomed  to  the  ether  odor.  The  patient  should  always  be  placed 
in  the  recumbent  posture  before  etherization  is  commenced ;  it  is  a  mistake, 
not  unaccompanied  by  risk,  to  attempt  anaesthesia  in  the  sitting  or  semi-re- 
cumbent posture.  Of  course,  all  constraint  of  clothing  should  be  removed 
from  the  neck  and  waist,  and  false  teeth  should  be  taken  out,  as  they  are  lia- 
ble to  become  displaced;  and  instances  have  occurred  in  which  they  have  been 
swallowed  during  insensibility.  If  any  operation  is  to  be  attempted  within 
the  mouth,  involving  the  separation  or  holding  apart  of  the  jaws  by  corks  or 
like  substances,  the  latter  should  be  controlled  externally  by  strings.  An  in- 
stance occurred  not  many  years  since  in  Philadelphia,  in  which  a  cork  used 
as  a  gag  was  drawn  into  the  larynx  by  violent  inspiration,  producing  an  im- 
mediately fatal  result. 

In  using  ether  it  is  well  to  watch  the  pulse  carefully  as  well  as  the  breath- 
ing. If  the  pulse  is  good,  the  patient  is  doing  well.  If  it  becomes  feeble  or 
infrequent,  the  ether  should  be  withdrawn  and  the  access  of  air  permitted. 
So  also  if  the  lividity  of  the  face  increases,  or  if  laryngeal  spasm  occurs,  more 
aii-  must  lie  given.  When  mucus  collects  in  the  mouth  and  fauces,  and  there 
is  usually  a,  good  deal,  it  must  be  removed;  and  if  from  any  cause  the  breath- 
ing seems  to  be  interfered  with,  or  deficient,  access  of  air  must  be  allowed  by 
opening  the  mouth  or  drawing  the  cheek  out,  and  seeing  that  the  tongue  is 
not  retracted.     Vomiting  when  it  occurs  should  be  met  by  turning  the  head 


AFTER-TREATMENT    OF   ETHER    ANESTHESIA.  445 

to  one  side,  so  that  the  mouth  may  be  dependent,  when  the  vomited  matters 
may  easily  be  gotten  rid  of. 

In  using  ether  at  night,  care  should  be  taken  to  keep  the  lights  above  the 
level  of  the  patient's  body,  so  as  to  prevent  ignition,  the  ether  vapor  being 
heavier  than  air.  So  also  in  operations  demanding  the  application  of  the 
actual  cautery,  the  possible  ignition  of  the  ether  vapor  should  be  carefully 
guarded  against.  By  practical  experience,  it  has  been  shown  that  this  acci- 
dent may  be  prevented  by  tanning  the  air  in  front  of  the  patient's  mouth  for 
a  moment  or  so  before  the  approach  of  the  hot  iron.  Nevertheless,  the  utmost 
care  in  this  respect  must  be  observed.  The  same  remarks  apply  to  the  careless 
use  or  too  great  proximity  of  the  spray-producer  in  Lister's  method,  which 
has  also  on  more  than  one  occasion  set  fire  to  the  ether.  Indeed,  it  may  be 
questioned  whether,  in  operations  where  ether  is  employed,  the  steam  atomizer 
should  be  used  at  all,  unless  in  those  upon  the  trunk  or  extremities.  The 
powerful  atomizer  arranged  by  Dr.  J.  Solis-Cohen  is  free  from  this  objection, 
since  in  it  the  spray  is  produced  under  atmospheric  pressure,  without  the 
employment  of  a  name. 

The  exhibition  of  ether  by  means  of  a  large  sponge,  once  so  universally 
adopted,  is  not  now  generally  resorted  to.  It  accomplishes  the  purpose  well 
enough,  but  is  attended  by  wasteful  expenditure  of  the  anaesthetic,  and  by  too 
great  an  impregnation  of  the  air  of  the  room. 

The  amount  of  ether  which  it  is  proper  to  use  in  an  operation,  of  course 
varies  greatly.  When  it  is  judiciously  administered,  when  its  effects  are 
carefully  watched,  and  when  its  exhibition  is  relaxed  from  time  to  time  upon 
the  appearance  of  too  marked  a  lividity  of  face,  its  influence  may  be  continued 
for  a  very  considerable  time.  In  the  treatment  of  a  subclavian  aneurism  by 
compression  exerted  by  a  tourniquet,  to  the  extent  of  cutting  off  all  arterial 
impulse,  the  writer  has,  on  several  occasions,  kept  the  patient  well  etherized 
for  six,  seven,  or  eight  hours  at  a  time.  But  it  must  be  remembered  that  no 
anaesthesia  is  altogether  safe,  and  the  risks  in  such  a  case  must  be  deliberately 
weighed  against  the  possible  advantages  to  be  gained.  Occasionally  patients 
are  met  with  who  seem  to  have  an  intermittent  respiration,  with  a  tend- 
ency to  lividity.  With  such  persons  extraordinary  care  must  be  used  in  the 
administration  of  an  anaesthetic,  and  atmospheric  air  must  be  freely  admitted. 

After-treatment  of  Ether  Anaesthesia.— A  matter  not  to  be  overlooked 
in  the  use  of  anaesthetics,  ether  as  well  as  chloroform,  is  the  after-care.  A 
patient  should  not  be  left  by  himself,  or  unwatched,  until  he  has  regained  his 
consciousness,  or  until  the  respiration,  circulation,  and  color  of  the  skin  have 
been  fairly  established.  Very  frequently,  anaesthesia  is  followed,  particularly 
in  children,  by  prolonged  sleep,  but  the  surgeon  will  feel  more  comfortable  in 
his  own  mind  if  the  patient  has  once  fairly  reacted  into  consciousness,  before 
being  allowed  to  pass  into  slumber.  Sponging  the  face  with  cold  water,  or 
slapping  the  face  and  chest  gently  with  a  wet  towel,  will  usually  bring  the 
patient  to  himself,  and  when  once  he  has  been  sufficiently  aroused  to  answer 
questions  put  to  him,  immediate  danger  may  be  regarded  as  having  passed 
away.  In  etherization,  however,  there  is  always  the  possibility  of  the  subse- 
quent pulmonary  complications  already  alluded  to,  and  it  is  difficult  to  say 
what  precautions  can  be  adopted  to  prevent  the  development  of  the  acute 
cedema  of  the  lungs,  -which,  once  established,  is  usually  so  destructive  to  the 
patient.  Fortunately,  however,  looking  at  the  vast  number  of  cases  in  which 
ether  is  given,  with  an  almost  absolute  impunity,  this  accident  is  very  rare  ; 
yet  it  is  still  a  contingency  which  may  occur.  In  cases  in  which  prolonged 
etherization  is  necessary,  Dr.  John  Ashhurst  directs  the  subsequent  adminis- 
tration of  carbonate  of  ammonium  in  doses  of  five  grains  every  half  hour, 


446  OPERATIVE   SURGERY   IN   GENERAL. 

hour,  or  two  hours,  according  to  circumstances,  until  all  risk  of  pulmonary 
congestion  and  oedema  has  passed  away. 

There  is  one  other  untoward  effect  of  etherization,  which  is  sometimes  met 
with,  and  which  does  not  appear  as  yet  to  have  been  fully  studied.  It  is  the 
suppression  of  urine,  and  uraemic  poisoning,  met  with  in  cases  where  disease 
of  the  kidney  has  been  pre-existent.  To  what  extent  this  condition  is  charge- 
able to  the  ether  used,  or  whether  it  is  rather  the  result  of  the  operation  itself, 
is  not  altogether  clear.  It  is  nevertheless  probable,  that  prolonged  anaesthesia,  * 
or  perhaps  we  should  say  etherization,  may  interfere  with  the  due  elimination 
of  the  urinary  constituents.  A  proper  examination  of  the  urine  should,  of 
course,  be  made  before  any  serious  operation  is  attempted,  and,  if  organic  dis- 
ease of  the  kidney  be  manifest,  the  operation  if  done  at  all  should  be  accom- 
panied by  as  short  a  duration  of  anaesthesia  as  is  consistent  with  the  circum- 
stances of  the  case. 

Administration  of  Chloroform. — In  Europe,  and  in  a  large  section  of 
America,  and  in  the  military  and  naval  services  of  different  countries,  chloro- 
form is  the  favorite  anaesthetic  agent.  In  the  late  civil  war  in  this  country, 
it  was  employed  by  both  combatants  almost  to  the  exclusion  of  ether  in 
armies  in  the  field,  and  in  very  many  of  the  large  hospitals  in  the  rear.  The 
convenience,  portability,  prompt  action,  and  pleasant  effects  of  chloroform 
are  everywhere  admitted,  and  have  already  been  referred  to.  It  remains  to 
consider  its  clanger ;  and  that  it  is  dangerous  is.  conceded  by  all,  even  by  those 
who  are  loudest  in  its  praise.  Very  many  excellent  surgeons  can  be  found 
who  have  used  chloroform  for  years,  without  an  accident,  and  who  have  never 
witnessed  an  accident  at  the  hands  of  others  from  its  employment.  Yet  the 
surgical  mind  is  undoubtedly  being  influenced  by  the  growing  death-roll 
which  has  marked  its  use.  In  Great  Britain  especially,  where  chloroform 
has  for  so  many  years  been  the  favorite  anaesthetic,  a  distrust  of  the  agent  is 
springing  up,  and  the  employment  of  sulphuric  ether  is  becoming  daily 
extended.  The  pages  of  the  medical  press  evince  this  altered  opinion  most 
distinctly,  and  that  it  is  a  judgment  based  upon  conviction,  no  one  can  doubt 
who  is  conversant  with  the  honesty,  good  faith,  and  wide  experience  of  the 
British  medical  profession. 

The  administration  of  chloroform  by  surgeons  in  this  country,  and  prob- 
ably by  the  major  portion  of  those  who  use  it  abroad,  is  effected  by  pouring 
a  drachm  of  the  drug  upon  a  piece  of  lint,  or  a  folded  towel  of  two  or  three 
thicknesses.  This  is  at  first  held  three  or  four  inches  from  the  face  of  the 
patient,  and  gradually  approximated  until  within  an  inch  of  the  nose.  Tree 
circulation  and  admixture  of  air  with  the  chloroform  are  thus  permitted. 
The  defect  of  this  mode  of  administration,  as  stated  by  Mr.  Erichsen,  is  that 
there  is  no  possibility  of  estimating  the  true  proportion  of  the  admixture  of 
air  and  chloroform,  and  that  the  administrator  can  only  judge  by  his  observa- 
tion of  the  resulting  effects.  To  remedy  this  uncertainty,  various  inhaling 
apparatuses  have  been  designed,  the  best  of  these,  to  quote  the  same  authority, 
being  those  of  Messrs.  Shaw  and  Clover.  In  that  of  the  latter,  the  mixture 
of  30  to  40  minims  of  chloroform  with  1000  cubic  inches  of  air  is  ingeniously 
accomplished,  and  from  a  bag  charged  with  this  mixture,  the  inhalation  by 
the  patient  is  effected  through  a  tube  and  mouth-piece. 

The  first  effect  of  chloroform  is  an  excitant  one  upon  the  nervous  system, 
and  upon  the  action  of  the  heart.  This  is  soon  followed  by  motor  and 
sensory  paralysis,  by  insensibility,  and  by  a  sedative  effect  upon  the  heart, 
with  feeble  respiration,  and  a  state  <>i'  greater  or  less  asphyxia.  At  this 
time,  if  the  chloroform  be  unduly  pressed,  there  is  danger  of  death  resulting. 


LOCAL   ANESTHESIA.  447 

The  occurrence  of  stertorous  breathing  indicates  that  the  administration  ot 
the  chloroform  should  cease. 

The  exhibition  of  chloroform  is  often  followed  by  effects  of  an  annoying 
character.  Thus  gastric  irritability,  accompanied  by  nausea  and  vomiting, 
may  supervene ;  this  does  not  happen  as  often  as  after  the  inhalation  of 
ether,  but,  when  it  does  occur,  it  is  apt  to  be  severe  and  depressing.  Slight 
congestion  of  the  lungs  is  also  met  with,  as  in  the  case  of  ether  administra- 
tion, but  it  is  not  so  common,  nor,  as  a  rule,  so  irritating.  Cephalic  troubles 
also  occasionally  take  place.  The  evil  effects  of  chloroform  are,  however, 
not  to  be  found  so  much  in  its  secondary  consequences,  as  in  the  liability  to 
death  at  the  time  of  administration,  or  during  or  after  an  operation.  When 
death  thus  occurs,  it  is  usually  immediate,  and  cannot  be  prevented ;  and  it 
may  be  charged  either  to  asphyxia,  to  coma,  or  to  syncope.  It  has  taken 
place  not  unfrequently  in  those  who  seemed  to  be  the  most  healthy,  and 
after  the  performance  of  the  slightest  operations  and  surgical  procedures, 
such  as  the  amputation  of  a  finger  or  the  passage  of  a  catheter.  It  is 
impossible  from  any  previous  examination  to  predicate  with  certainty  the 
chances  of  danger,  and  it  would  seem  also  equally  difficult  to  treat  them 
when  once  fairly  developed.  As  we  have  already  said,  in  all  anaesthesia 
there  is  some  danger,  and  in  the  anaesthesia  from  chloroform  the  chances  of 
danger  are  greater  than  those  attendant  upon  the  use  of  its  rival — ether. 

Should  it  unfortunately  happen,  during  the  administration  of  chloroform, 
that  any  of  the  dangers  referred  to  are  present  or  threatening,  the  most 
active  measures  must  be  adopted  to  check  them  or  ward  them  off.  The 
chloroform  should  be  immediately  withdrawn ;  fresh  air  admitted ;  cold 
water  dashed  upon  the  face ;  the  tongue,  if  retracted,  drawn  forward  ;  and 
prompt  efforts  at  artificial  respiration  instituted.  If  the  effect  of  the  drug 
fall  chiefly  on  the  heart,  as  evinced  by  the  state  of  syncope,  its  action  should 
be  stimulated  by  electro-galvanism,  the  poles  of  the  apparatus  being  applied 
on  the  chest  and  diaphragm  and  over  the  spine.  Mr.  Erichsen,  in  his 
valuable  remarks  on  this  subject,  speaks  of  the  use  of  nitrite  of  amyl, 
referring  to  the .  experiments  of  Dabney.  From  what  I  have  seen  of  the 
effect  of  this  drug  as  an  antidote  to  an  overdose  of  bromide  of  ethyl,  an 
agent  which  is  certainly  as  sudden  and  fearful  in  its  action  as  chloroform, 
and  probably  much  more  so,  it  would  seem  that  the  nitrite  of  amyl  exercised 
a  most  powerful  influence  in  raising  the  patient  from  a  condition  of  syncope 
or  asphyxia,  and  in  establishing  reaction.  The  quantity  employed  in  the  cases 
referred  to  was  twenty  or  twenty-five  drops,  and  its  action  was  immediate. 

Local  Anaesthesia,  the  result  of  extreme  cold  produced  by  different 
methods,  may  sometimes  be  advantageously  employed  in  slight  operations, 
such  as  the  opening  of  abscesses  or  the  removal  of  a  toe-nail.  It  is,  however, 
not  applicable  to  operations  in  which  deep  tissues  are  divided,  but  is  limited  to 
skip-deep  incisions  only.  It  can  be  conveniently  brought  about  by  the  appli- 
cation of  a  piece  of  ice  on  which  a  little  common  salt  has  been  sprinkled, 
covered  by  a  single  layer  of  a  towel,  and  kept  steadily  upon  the  part  for 
three  minutes.  It  can  also  be  obtained  more  perfectly  by  the  spray  of  pure 
ether,  or  by  that  of  rhigolene.  The  latter  will  freeze  the  tissues  to  some  depth, 
but  perfect  congelation,  at  times,  renders  it  difficult  to  distinguish,  during 
operation,  abnormal  from  healthy  tissues.  This  excessive  freezing  is  also 
sometimes  followed  by  too  great  a  reaction,  and  by  sloughing.  For  these 
minor  operations,  when  merely  a  temporary  and,  as  it  were,"local  insensi- 
bility is  desired,  the  transitory  effects  of  the  inhalation  of  ether  already 
described  may  be  preferably  substituted. 


448  OPERATIVE   SURGFRY    IN   GENERAL. 

Other  Means  of  Producing  Anesthesia. — Allusion  has  already  been 
made  to  the  use  of  the  vapor  of  bromide  of  ethyl  as  an  anaesthetic  agent.  Its 
properties  in  this  respect  were  first  demonstrated  by  Mr.  Nunnery,  of  Leeds, 
who,  in  1865,  used  it  in  surgical  operations.  The  difficulty  of  its  prepara- 
tion and  its  great  cost  led,  however,  to  its  abandonment,  especially  as  at  that 
time  it  did  not  appear  to  possess  any  qualities  which  rendered  its  employ- 
ment more  advantageous  than  that  of  other  substances.  In  1879,  its  use  was 
revived  by  Drs.  Levis  and  Turnbull  in  Philadelphia,  and  a  wide  application 
of  its  powers  was  speedily  made.  At  a  first  view,  it  seemed  that  the  long- 
desired  anaesthetic  had  at  last  been  found  in  an  agent  which  was  not  disagree- 
able to  inhale,  which  produced  anaesthesia  with  great  promptness  and  without 
much  nausea  or  vomiting,  and  from  the  effects  of  which  the  patient  recovered 
as  rapidly  as  he  had  passed  under  them.  More  extended  observation,  how- 
ever, showed  that  the  employment  of  the  new  agent  was  fraught  with  danger, 
and  that  its  seductive  qualities  were  more  than  counterbalanced  by  their 
attendant  perils.  Its  exhibition  was  marked  by  rapidly  developed  anaesthesia, 
accompanied  by  much  muscular  rigidity  and  spasm,  apparently  of  a  tetanic 
character,  and,  at  times,  reaching  almost  to  opisthotonos.  While  in  the  great 
majority  of  cases  patients  did  well,  still,  instances  occurred  in  which  they 
wTere  rescued  from  the  combined  condition  of  coma  and  asphyxia  only  by  the 
most  active  measures,  including  the  use  of  the  nitrite  of  amyl.  Excellent 
and  powerful  as  the  agent  was  in  many  respects,  its  continued  use  seemed  to 
be  undesirable  on  account  of  the  certain  peril  which  attended  it.  Its  em- 
ployment has,  therefore,  been  abandoned,  and,  as  we  think,  wisely. 

The  employment,  under  the  name  of  chloric  ether,  of  a  mixture  of  ether  and 
chloroform,  has  been  strongly  advocated  by  many  surgeons.  It  has  been 
stated  that,  by  the  admixture  of  one  part  of  chloroform  to  five  of  ether  by 
weight,  a  compound  agent  is  obtained  which  combines  the  advantages  of 
ether  and  chloroform,  and  is  yet  free  from  the  objections  to  both — the 
stimulating  effects  of  the  former  counteracting  the  depressing  influences  of 
the  latter.  By  some  the  proportion  of  chloroform  in  the  mixture  is  greatly 
increased.  There  is  no  doubt  that  "chloric  ether"  acts  promptly  and  effi- 
ciently, but  it  is  questionable  whether  the  dangers  incident  to  chloroform  do 
not  still  exist,  since  it  is  probable  that  the  chloroform  acts  in  its  characteristic 
manner,  unchanged  by  its  combination,  or  rather  mixture,  with  ether.  From 
a  prolonged  experience  with  this  compound  agent,  the  writer  believes  that 
the  alleged  immunity  to  danger  is  not  obtained,  and  that  the  chloroform  still 
exerts  its  effects  as  chloroform  per  se. 

Nitrous  oxide  is  occasionally  employed  as  an  anaesthetic.  Its  use  is,  how- 
ever, greatly  restricted  by  its  transitory  effects,  and  by  the  rapidity  with 
which  the  patient  emerges  from  its  influence.  It  is  only  suitable  for  the 
slightest  operations,  and  possesses  no  advantages  over  ether  employed  as 
already  described. 


Mode  of  Conducting  an  Operation. 

In  the  performance  of  the  operation  itself,  the  skill,  readiness,  and  self-com- 
mand  of  the  Burgeon  are  tested  to  the  utmost.  He  should  always  be  master 
of  the  situation,  and  should  stand  prepared  for  every  emergency.  Order 
must  characterize  all  his  arrangements,  and  every  step  must  be  well  considered 
beforehand, and  executed  with  promptness — free  from  hesitation,  and  yet  de- 
void <>)'  all  appearance  of  haste.  The  same  deliberation  should  characterize 
the  liual  as  the  initial  *\v\)*  «.f  the  operation.  Sir  James  Paget,  in  his  admi- 
rable chapter  on  the  "Calamities  of  Surgery,"  has  so  vividly  portrayed  that 


MODE   OF   CONDUCTING   AN   OPERATION.  449 

condition  of  mind  which  every  operator  must  have  felt  towards  the  close  of 
a  serious  operation,  that  his  words  deserve  to  be  indelibly  imprinted  on  the 
mind  of  the  surgeon.     He  says : — 

"  Be  quite  clear  about  carrying  out  carefully  the  last  stages  of  all  operations.  I  sus- 
pect that  everybody  in  operating,  when  he  has  passed  through  the  sort  of  mental  tension 
in  which  he  performs  the  most  difficult  part  of  what  he  has  to  do,  when  his  attention 
has  been  completely  occupied  in  some  difficult  task  to  be  achieved,  next  feels  his  mind 
relaxed,  his  attention  less  keen,  less  ready  for  exercise  than  it  was  before.  Be  sure 
that  these  are  times  of  danger  to  your  patient  ;  as  soon  as  the  attention  ceases  to  be  as 
keen  as  possible,  you  are  in  risk  of  doing  some  mischief." 

Few  operations  can  be  performed  by  the  surgeon  alone.  In  most  cases  he 
requires  professional  aid,  and  this  should  be  rendered  by  trained  assistants, 
accustomed  to  operations,  and,  if  possible,  in  the  habit  of  assisting  the  indi- 
vidual operator.  These  gentlemen  should  be  efficient  but  not  officious.  Their 
duties  should  be  assigned  to  them  03'  the  surgeon  himself,  and  should  be  per- 
formed by  them  in  perfect  quiet,  and  in  a  manner  calculated  to  assist  and  not 
to  embarrass  the  operator.  An  able  assistant  is  of  the  greatest  use,  while  an 
inefficient  one  is  only  a  source  of  annoyance  to  his  principal.  The  time  most 
suitable  for  operation  is  near  the  middle  of  the  day,  as  the  light  is  then  at  its 
best.  Care  should  be  taken  that  the  patient's  breakfast  has  been  a  simple 
one,  and  that  his  stomach  is  not  overloaded  when  the  period  for  operation 
has  arrived. 

For  most  operations  the  patient  should  be  in  the  recumbent  posture,  as  loss 
of  blood  is  then  more  readily  borne,  ana?sthesia  can  be  best  effected,  and  there 
is  much  less  chance  of  syncope.  He  should  be  placed  on  a  table  of  proper 
height,  and  one  can  usually  be  formed  by  utilizing  articles  of  room  furniture, 
such  as  two  small  tables,  or  a  table  and  washstand,  and  then  covering  them 
with  blankets.  The  improvised  table  can  then  be  brought  near  to  a  window, 
and  in  full  light.  Attention  to  the  matter  of  the  operating  table  is  of  more 
consequence  than  is  usually  supposed ;  for  it  enables  the  surgeon  to  discharge 
his  duties  in  comfort  to  himself,  and  without  that  strain  and  weariness  in  the 
back  which  is  invariably  felt  when  the  operator  is  obliged  to  bend  down  in  a 
constrained  position  over  a  low  bed.  Attention  at  the  same  time  must  be 
paid  to  the  patient's  comfort,  or  rather  to  his  well-being,  while  on  the  table 
and  under  the  anaesthetic.  He  ought  not  to  be  unnecessarily  exposed  to  the 
air,  but  should  be  kept  warm.  The  trunk  and  the  lower  extremities  must 
be  carefully  covered,  since  there  is  always,  during  an  operation,  a  tendency  to 
a  decrease  in  the  temperature  of  the  body.  In  operations  upon  the  urinary 
and  genital  organs,  when  the  lower  part  of  the  body  must  be  uncovered  to  a 
certain  extent,  the  legs  of  a  pair  of  drawers,  divided  in  the  crotch,  can  be 
drawn  over  the  lower  limbs.  If  laxity  be  permitted  in  this  respect,  and  the 
temperature  of  the  body  be  allowed  to  fall  unduly,  an  additional  element  of 
shock  is  created.  Too  much  precaution  cannot  be  exerted  in  this  matter, 
particularly  in  the  case  of  delicate  persons,  women,  and  children. 

The  immediate  dangers  of  operation  are  hemorrhage  and  shock.  The  former 
must  be  prevented  by  every  possible  means,  as  the  loss  of  an  extra  ounce  or 
so  of  blood  is  often  the  turning  point  in  a  case.  In  children  particularly  it 
should  be  guarded  against,  since  they  bear  bleeding  very  badly.  Fortunately, 
in  Esmarch's  elastic  bandage  we  have  a  means  of  practising  many  serious  ope- 
rations without  the  loss  of  blood.  A  new  department  of  surgery  has  thus 
been  created — bloodless  surgery — which  is  applicable  not  only  to  amputations, 
but  indeed  to  all  operations  upon  the  extremities.  It  is  scarcely  necessary  to 
describe  the  apparatus  here.  As  is  well  known,  it  consists  of  two  elastic  ban- 
dages, one  of  which  is  wound  around  the  limb  from  its  distal  extremity  to 
vol.  1.— 29 


450  OPERATIVE    SURGERY    IN   GENERAL. 

above  the  point  of  operation,  thus  expelling  the  blood  from  the  part,  and 
leaving  the  tissues  completely  exsanguine.  The  second  rubber  band,  thicker 
and  stronger  than  the  former,  is  then  carried  two  or  three  times  around  the 
part,  with  sufficient  tension  to  thoroughly  compress  the  soft  tissues,  and  cut 
off  the  circulation  in  the  arterial  trunks.  The  first  band  is  then  removed, 
when  the  operation  can  be  performed  without  bleeding,  and  with  the  same 
facility  as  on  the  limb  of  a  cadaver.  In  applying  the  second  constricting 
band,  care  must  be  taken  not  to  draw  it  too  tightly ;  if  this  be  done,  there  will  be 
danger  of  sloughing  ;  this  is  not  an  imaginary  evil,  but  has  occurred,  and  the 
resulting  ulcers  have  been  deep,  unmanageable,  and  difficult  to  heal.  The 
broad  thick  band  is  preferable  to  the  tubing,  which  has  been  so  much  used, 
since  the  latter  on  being  stretched  acts  as  a  cord,  and  is  apt  to  produce  mis- 
chief. If  the  reader  doubts  this  assertion,  let  him  try  the  experiment  of  the 
application  of  these  rubbers  upon  his  own  person,  and  he  will  be  quickly  con- 
vinced of  the  power  of  their  action.  There  is  another  precaution  which  it  is 
well  to  observe  in  the  use  of  the  upper  constricting  band  ;  this  is,  not  to  ap- 
ply it  when  the  muscles  and  tissues  which  it  constricts  are  in  a  state  of 
shortening  or  flexion.  If  this  mistake  be  made,  and  the  distal  portion  of  the 
limb  be  afterwards  extended,  as  may  be  necessary  during  an  amputation,  injury 
or  laceration  of  the  upper  structures  may  take  place,  thus  causing  troublesome 
after-consequences,  or  even  deep  sloughing.  A  question  has  arisen  as  to  the 
propriety  of  making  much  pressure,  with  the  first  bandage  of  Esmarch,  over 
suppurating  or  gangrenous  tissues,  or  even  malignant  growths,  and  it  has 
been  urged  that,  by  so  doing,  disorganized  and  morbid  elements  might  be 
forced  into  the  general  circulation.  Whether  this  be  so  or  not,  it  is  difficult 
to  say  ;  at  the  same  time,  it  is  a  contingency  which  it  is  worth  while  for  sur- 
geons to  bear  in  mind. 

A  plan  of  emptying  a  limb  of  blood  by  simply  elevating  it  to  the  highest 
point,  and  then  stroking  it  for  a  minute  or  more  in  the  direction  of  the  venous 
circulation,  has  of  late  years  been  practised  in  Great  Britain,  and  is  described 
by  Mr.  Erichsen  as  "Lister's  method."  It  is  one,  however,  which  has  long 
been  familiar  to  the  American  profession,  and  was  witnessed  by  the  writer 
in  the  hands  of  Pancoast  of  Philadelphia,  nearly  thirty  years  since. 

Before  beginning  an  operation,  the  surgeon  should  see  that  the  proper  in- 
struments have  been  laid  out,  and  that  they  are  in  good  condition,  and,  if  he 
intends  to  employ  complicated  apparatus,  that  it  is  in  working  order.  Neglect 
of  this  precaution  is  often  attended  with  great  annoyance,  and  these  matters 
should  not  be  entrusted  to  an  assistant,  but  should  pass  beneath  the  sur- 
geon's own  eye.  If  the  operation  be  a  cutting  one,  all  incisions  must  be 
deliberately  planned,  and  made  without  faltering.  Haste  should  be  avoided, 
but  each  stroke  of  the  knife  should  be  an  onward  step  in  the  operation,  and 
piecemeal  or  imperfect  work  ought  not  to  be  permitted.  The  first  cut  should 
divide  the  entire  thickness  of  the  skin,  and  the  succeeding  one,  if  the  opera- 
tion be  a  deep  one,  as  the  ligature  of  an  artery,  should  be  of  the  same  length. 
The  division  of  the  deep  structures  will  thus  be  as  long,  or  nearly  so,  as  the 
first  incision,  and  full  opportunity  will  be  afforded  the  operator  to  make  the 
necessary  search  at  the  bottom  of  the  wound.  When  this  course  is  not  fol- 
lowed, the  lowest  portion  of  the  wound  will  often  be  so  contracted  as  to  pre- 
vent full  examination.  The  wound  will  in  fact  be  a  cone,  with  the  apex 
downwards,  a  most  undesirable  result.  In  making  dissections  and  incisions, 
if  the  bloodless  method  is  not  adopted,  it  is  well  to  tie  the  larger  vessels  as 
they  bleed,  while  (lie  smaller  ones  can  be  left  until  the  conclusion  of  the  ope- 
ration.  For  the  ligature  of  vessels,  the  ordinary  silk  or  linen  thread,  or  the 
carbolized  cat-gut  ligatures,  may  beemployed.  Acupressure  pins  may  at  times 
be  conveniently  substituted  for  the  ligatures,  not  only  for  the  purpose  of  con- 


MODE  OF  CONDUCTING  AN  OPERATION.  451 

trolling  existing  hemorrhage,  but  also  for  preventing  it  in  regions  where 
Esmarch's  bandages  arc  not  applicable.  Thus  if  a  pin  be  passed  beneath  the 
facial  artery  as  it  mounts  over  the  lower  jawbone,  plastic  procedures  may  be 
readily  practised  on  the  face  with  little  loss  of  blood;  and  in  the  same  man- 
ner, operations  around  the  mouth  and  lips  may  be  greatly  facilitated  by  judi- 
ciously transfixing  the  adjacent  tissues  with  acupressure  needles,  around  which 
strong  compressing  threads  are  carried.  In  cleansing  the  wound,  sponges  may 
be  used,  but  they  "should  then  have  been  previously  washed  in  carbolic  acid 
solution  to  prevent  infection  of  the  wound;  or  clean  napkins  may  be  profitably 
substituted. 

In  the  removal  of  tumors,  as  for  example  of  the  mammary  gland,  bleeding 
can  often  be  prevented  to  a  great  degree  by  tearing  the  tissues  with  the  end 
of  the  finger,  rather  than  by  cutting  them  with  the  knife.  When  enucleation 
is  thus  effected,  the  vessels  contract,  there  is  but  little  bleeding,  the  outlying 
diseased  portions  come  away  with  the  affected  mass,  and  the  operation  is 
quickly  over.  Under  certain  circumstances,  where  the  tissues  are  tight,  and 
bind,  and  the  divulsion  cannot  be  conveniently  effected  by  the  end  of  the  fin- 
ger, knives  with  silver  or  rounded  blunt  steel  edges — "  dry  dissectors" — may 
be  resorted  to.  When  after-oozing  takes  place,  from  incised  wounds,  or  from 
the  face  of  stumps,  it  may  be  checked  by  the  use  of  cold  water  or  ice,  or  better 
still  by  sponges  or  napkins  wrung  out  of  very  hot  water,  or  by  hot  water  it- 
self. In  the  application  of  the  actual  cautery,  care  must  be  taken  to  avoid 
the  ignition  of  ether  vapor,  when  it  is  the  anaesthetic  employed.  Deep  caute- 
rization may  at  times  be  conveniently  effected  by  Paquelin's  thermo-cautery, 
but  this  should  be  tested  before  operation,  since  it  often  fails  to  become  heated 
at  the  critical  moment.  The  proper  fluid  to  be  used  in  this  instrument  is 
painter's  benzine  of  0.715  specific  gravity.  Wounds  of  operation,  particularly 
when  of  any  extent,  should  not  be  closed  until  all  bleeding  has  ceased,  since 
the  presence  of  blood  interferes  with  immediate  union.  For  drawing  the  lips 
of  the  wound  together,  sutures  of  silk,  or  fine  silver,  or  soft  iron  wire,  may  be 
employed.  The  latter  should  not  be  used  upon  the  face  or  exposed  parts,  since 
the  oxidation  of  the  iron  leaves  a  small  discolored  point  which  does  not  disap- 
pear for  some  time.  When  possible,  the  sutures  should  be  inserted  before  the 
patient  recovers  from  the  influence  of  the  anaesthetic. 

Perhaps  the  most  important  matter  in  the  healing  of  wounds  is  the  estab- 
lishment of  free  drainage.  Surgeons  may  be  greatly  divided  as  to  the  par- 
ticular form  of  after-dressing,  but  nearly  all  agree  as  to  the  necessity  of 
drainage.  It  is  therefore  incumbent  upon  the  operator  to  see  that  his  wound 
is  not  closed  too  tightly,  but  that  a  free  escape  is  afforded  for  all  fluids  which 
may  form.  In  deep  wounds,  this  can  be  best  accomplished  by  the  insertion, 
lief* >re  closure,  of  a  small,  perforated,  rubber  tube,  through  which  these  fluids 
can  escape.  After  six  or  seven  days,  the  tube  can  be  gradually  withdrawn  by 
cutting  off  half  an  inch  or  an  inch  daily  ;  when  the  drainage  through  its  track 
will  be  found  sufficient  to  keep  the  wound  free.  If  the  rubber  tube  be  left 
too  long  in  situ,  it  may  possibly  serve  to  keep  up  the  purulent  discharge. 

The  after-dressing  of  the  wounds  of  operation  has  been  a  matter  of  much 
discussion,  and  the  surgical  world,  sometimes  influenced  by  fashion,  epidemic 
opinion,  or  honest  conviction,  has  been  greatly  divided.  Poultices,  water- 
dressings,  dry  dressings,  earth  dressings,  cerate  cloths,  open  air  dressings,  and 
many  other  forms  of  topical  application,  have  all  had  in  their  day  active  .sup- 
porters, and  have  doubtless  furnished  excellent  results.  At  the  present  mo- 
ment, the  antiseptic  treatment  of  Professor  Lister  is  on  trial.  It  has  a  host 
of  ardent  partisans,  many  lukewarm  supporters,  and  some,  perhaps  not  a  great 
many,  opponents.  Whether  it  has  realized,  whether  it  will  realize,  all  that 
has  been  claimed,  and  all  that  is  hoped  from  it,  remains  to  be  seen.     But  the 


452  OPERATIVE    SURGERY    IN   GENERAL. 

earnest  and  enthusiastic  efforts  of  Professor  Lister  have  already  wrought  great 
good  to  surgery,  in  many  ways  ;  not  the  least  heing  in  the  care  and  cleanliness 
in  the  treatment  of  wounds,  which  he  has  taught,  and  in  the  personal  obser- 
vation and  attention  he  has  enforced  by  his  own  example.  As  the  antiseptic 
treatment  of  wounds  will  form  the  subject  of  a  separate  article,  it  is  not  neces- 
sary to -consider  it  further  in  this  place. 

Yet  apart  from  the  antiseptic  method  in  all  its  details,  it  is  probable  that, 
in  a  modified  form,  it  can  be  made  largely  and  conveniently  available  in  the 
treatment  of  wounds  of  operation,  and  open  injuries.  A  piece  of  lint  saturated 
with  carbolized  oil,  or  carbolated  solution,  will  answer  every  practical  pur- 
pose, and  may  be  substituted  for  the  rather  cumbersome  special  dressing  of 
Lister. 

No  matter  what  dressing  may  be  resorted  to,  the  surgeon  must  still  remem- 
ber that  it  should  at  all  times  be  inspected  with  repeated  and  scrupulous  care; 
that  soiled  cloths,  breeders  of  infection,  must  be  at  once  removed  ;  and  that 
absolute  cleanliness  of  the  wound  and  all  its  surroundings  must  be  rigidly 
.enforced.  If  there  be  much  suppuration,  the  carbolic  acid  spray  from  an  ordi- 
nary atomizer  can  be  advantageously  employed.  All  dressings  should  be 
light,  and  in  changing  them  great  gentleness  should  be  used  to  avoid  disturb- 
ing the  soft  parts,  and  arresting  or  interfering  with  the  process  of  union.  If 
adhesive  straps  have  been  laid  across  the  line  of  the  wound,  and  it  becomes 
necessary  to  change  them,  this  should  be  done  in  accordance  with  the  great 
indication,  the  preservation  of  local  rest. 


Treatment  of  Patients  after  Operation. 

The  after-treatment  of  operations-  may  conveniently  be  considered  as  local, 
and  general.  As  regards  the  former,  the  part  must  be  placed  in  the  position  of 
greatest  comfort  to  the  patient, and  properly  supported,  while  all  strain  upon  the 
tissues  is  avoided.  The  position,  too,  should  be  selected  so  as  to  favor  drainage, 
and  the  dressings  should  be  as  light,  and  as  little  cumbersome,  as  possible, 
while  every  attempt  should  be  made  to  favor  early  union.  If  the  sutures  used 
are  metallic,  and  are  productive  of  little  irritation,  they  may  be  left  until  it 
becomes  evident  that  they  are  of  no  further  service,  or  until  they  begin  to  cut 
out,  when  they  may  be  removed.  If  the  arteries  have  been  tied  with  thread 
or  silk  ligatures,  the  latter  must  be  left  until  it  is  apparent  that  they  are  sepa- 
rating or  falling.  They  must  always  be  handled  with  extreme  caution,  and 
no  force  should  be  employed  to  effect  their  dislodgment,  for  fear  of  pulling 
them  off  prematurely,  and  thus  giving  rise  to  bleeding  which  might  prove 
troublesome.  In  arranging  the  threads,  before  closing  the  wound,  it  is  well, 
as  a  rule,  to  carry  them  out  either  at  the  nearest  point,  or  at  the  angles, 
and  they  should  be  laid  straight  in  the  wound ;  care  must  also  be  taken  to  pre- 
vent them  from  felling  into  loops,  or  from  becoming  entangled  one  with  another ; 
otherwise,  in  removing  one  which  has  fallen,  an  unsuspected  ligature  may  be 
unduly  pulled  upon.  It  is  well,  too,  to  count  the  ligatures,  and  to  be  quite 
sure  as  the  ease  progresses  that  the  full  quota  of  threads  has  been  taken  away. 
Instances  are  not  uncommon,  where  many  ligatures  have  been  applied,  in 
which  one  or  more  have  in  some  way  or  other  become  buried  or  hidden  in 
the  depths  of  the  wound,  and,  to  the  mortification  of  the  surgeon,  have  made 
their  appearance  by  ulceration  weeks  after  the  wound  had  been  regarded  as 
firmly  closed  and  cicatrized.  When  the  carbolized  gut  ligatures  have  been 
used,  their  removal  will  necessarily  be  spontaneous  and  by  absorption,  and 
the  surgeon  need  not  trouble  himself  as  to  their  coming  away.  Rest,  support, 
drainage,   cleanliness,   the  avoidance  of  unnecessary   handling,  with   proper 


TREATMENT    OF    PATIENTS    AFTER    OPERATION.  453 

attention  to  the  ligatures  and  sutures,  constitute  in  short  the  local  after-treat- 
ment of  the  wound  of  operation.  To  these  must  be  added  constant  watchful- 
ness to  detect  the  development  of  abscesses,  and  the  requisite  incisions  for  their 
evacuation  should  any  form.  In  fulfilling  the  above  requirements,  the  surgeon 
must  bear  in  mind  that,  while  it  is  incumbent  upon  him  to  do  what  is  neces- 
sary, and  that  promptly,  on  the  proper  indications,  he  must  nevertheless  ab- 
stain from  officiousness  or  fussincss. 

After  an  operation  has  been  finished,  and  the  wound  satisfactorily  dressed, 
the  patient  should  be  placed  in  bed,  well  covered,  and  carefully  watched 
until  he  has  recovered  from  the  effects  of  the  anaesthesia.  Until  he  has 
done  so,  he  must  not  be  left  alone,  or  in  the  hands  of  an  inexperienced 
assistant,  or  in  those  of  a  nurse.  It  is  the  duty  of  the  surgeon  himself  not 
to  leave  his  patient  until  he  has  recovered  at  least  sufficient  consciousness  to 
answer  questions.  The  general  after-treatment  now  begins,  and  upon  it  the 
ultimate  issue  of  the  case  in  no  little  degree  depends.  The  first  general 
indication  is  rest:  rest  to  body  and  mind,  relief  from  excitement,  and  freedom 
from  pain.  There  is  no  doubt  that  these  ends  can  be  best  brought  about  by 
the  exhibition  of  an  anodyne,  and  in  no  better  way  than  by  the  subcutaneous 
use  of  morphia.  A  hypodermic  injection  of  from  a  quarter  to  a  half  grain, 
will  usually  be  sufficient  to  prevent  pain  and  soothe  restlessness.  In  excep- 
tional cases  more  may  be  required,  but  the  amount  mentioned  is  usually 
sufficient,  and,  if  not,  it  can  be  repeated.  When  it  acts,  the  patient  passes  off 
into  quiet  sleep,  and  thus  escapes  the  shock  of  pain  which  would  otherwise 
greet  him  so  unpleasantly  on  his  recovery  from  anaesthesia.  Of  course,  if  an 
hypodermic  have  been  given  prior  to  the  operation,  this  fact  must  be  remem- 
bered in  apportioning  the  after-medication.  Xot  unfrequently  after  operation 
a  good  deal  of  nausea  is  present  from  the  effects  of  the  ether  or  chloroform. 
This  commonly  passes  off  gradually  in  a  few  hours,  but  sometimes  continues 
throughout  the  night  and  even  into  the  next  day.  When  prolonged,  it  is 
difficult  of  treatment  and  not  readily  amenable  to  drugs.  Occasionally  it  is 
relieved  by  ice  in  small  quantities,  by  a  teaspoonful  or  so  of  brandy,  by 
carbonated  waters,  or  by  sinapisms  to  the  epigastrium.  It  is  sometimes 
ameliorated  by  vomiting,  although  not  always. 

In  most  cases  of  serious  operation,  especially  if  the  nausea  above  described 
be  present,  the  patient  does  not  desire  food  of  any  kind,  and,  indeed,  cannot 
retain  it  even  if  he  forces  it  down.  Great  care  must,  therefore,  be  exerted  in 
selecting  the  proper  nourishment.  It  would  seem  that  the  diet  most  suitable 
under  these  circumstances  was  milk,  or  milk  diluted  with  lime-water.  This 
can  generally  be  retained,  is  palatable  to  the  patient,  and  gratefully  assuages 
the  thirst  which  is  often  so  terrible  to  bear.  Physiologically  considered,  too, 
it  is  that  form  of  nutriment  best  adapted  to  cases  where  there  has  been  much 
loss  of  blood ;  in  fact,  it  would  almost  appear  to  satisfy  a  natural  craving. 
Few  patients  object  to  it ;  and  even  those  who  at  first  say  that  they  "  cannot 
bear  milk — it  does  not  agree  with  them,"  yet  take  it  willingly  and  even 
eagerly  after  the  first  trial.  In  administering  milk,  caution  should  be  exer- 
cised as  to  the  quantity.  Too  much  should  not  be  given  at  one  time,  but 
small  quantities,  repeated,  and  taken  slowly.  If  the  stomach  be  very  irritable, 
an  ounce  and  a  half  or  two  ounces  every  two  hours  will  be  sufficient.  If  the 
patient  be  very  weak,  brandy  or  whiskey  can  be  given  with  the  milk,  or  in 
alternate  doses,  according  to  the  indications.  Beef  essence  is  not  always  well 
received  by  the  stomach,  nor  are  soups,  however  nicely  they  may  be  made. 
They  are  undoubtedly  satisfactory  articles  of  diet  after  the  lapse  of  a  day  or 
two,  but  are  not  so  well  borne  immediately  after  the  operation.  In  many 
cases,  particularly  where  thirst  is  annoying,  acidulated  drinks  may  be  admin- 


454  OPERATIVE    SURGERY    IN   GENERAL. 

istered  with  benefit.  The  combination  of  milk  with  occasional  small  quan- 
tities of  lemonade  may  at  first  thoughts  appear  to  be  somewhat  incongruous, 
yet  clinical  experience  fully  asserts  their  value,  especially  in  operations  upon 
the  urinary  organs.  As  the  case  progresses,  and  as  the  patient  improves,  the 
diet  may  be  increased  in  strength  and  quantity,  and  richer  soups,  the  breast 
of  a  chicken,  or  the  more  digestible  meats  may  be  given.  In  every  instance, 
the  selection  of  diet  must  be  governed  by  the  circumstances  of  the  patient. 
If  there  is  a  tendency  to  inflammation,  it  must  be  light ;  while  for  those  who 
are  weak,  or  who  have  suffered  much  from  shock  or  hemorrhage,  fuller  diet 
is  demanded.  A  good  deal  can  be  left  to  the  patient's  inclination,  for  he  can 
sometimes  judge  better  than  those  who  are  around  him  as  to  what  he  can 
most  easily  retain  on  his  stomach  ;  and  his  fancies  in  this  respect  should  be 
considered  when  not  obviously  objectionable. 

Before  operation,  the  patient  should  be  instructed  to  empty  the  bladder. 
If  this  be  not  attended  to,  an  early  use  of  the  catheter  may  be  demanded, 
since  many  persons  experience  great  difficulty  in  voiding  their  urine  after 
operation.  It  is,  perhaps,  unnecessary  to  state  that  the  bowels  should  be 
freely  evacuated  on  the  morning  before  the  operation.  This  is  all  the  more 
to  be  insisted  upon,  since  constipation  usually  follows  operation.  This  may 
be  due  in  part  to  the  loss  of  blood,  and  in  part  to  the  opiates  given,  and  the 
confinement  to  bed.  It  is  not,  however,  a  circumstance  which  need  give  rise 
to  any  uneasiness,  or  indicate  hasty  administration  of  purgatives.  It  is 
usually  corrected  by  the  change  of  diet,  and,  if  it  is  not,  a  little  castor  oil 
after  a  few  days  will  answer  evevy  purpose.  The  use  of  purgatives  in  any 
shape  too  soon  after  operation  is  greatly  to  be  deprecated.  In  the  first  place, 
they  are  unnecessary,  and,  in  the  second,  too  early  a  movement  of  the  bowels 
sometimes  overtaxes  the  patient's  strength  and  is  followed  by  exhaustion. 
Should  the  bowels  act,  it  is  well  to  give  a  little  stimulus  at  the  time. 

In  rare  instances,  patients  are  met  with  who  bear  operations  with  wonder- 
ful composure  and  recover  with  remarkable  facility. 

The  writer  can  recall,  as  such,  a  case  of  secondary  amputation  at  the  knee-joint,  upon 
a  delicate  lady.  On  the  following  morning  she  was  found  sitting  up  in  bed  knitting, 
and  she  had  insisted  upon  her  customary  diet  without  any  abatement.  The  popliteal 
ligature  separated  on  the  tenth  day,  the  wound  healed  by  first  intention,  and  in  reality 
in  less  than  ten  days  she  was  well. 

Another  singular  instance  occurred  in  an  Irish  soldier  whose  humerus  was  shattered 
in  action  by  a  ball,  and  whose  arm  was  removed  close  to  the  shoulder-joint  immediately 
afterwards.  He  walked  on  the  same  day,  under  a  broiling  sun,  fifteen  miles,  carrying 
his  gun,  knapsack,  and  full  accoutrements,  and  in  the  evening  was  found  acting  as  a 
volunteer  sentry  on  guard.  He  was  with  difficulty  placed  in  hospital  ;  the  ligature 
separated  early,  and  his  recovery  was  as  rapid  and  wonderful  as  in  the  case  above 
given.     In  neither  of  these  instances  was  traumatic  fever  developed. 

There  is  yet  one  other  matter  which  it  is  well  for  the  surgeon  to  see  to,  and 
that  is  the  character  of  the  patient's  surroundings.  Not  only  should  his  room 
be  well  ventilated,  but  it  should  be  light  and  cheerful  ;  and,  as  he  convalesces, 
he  should  be  provided  with  proper  books,  and  resources  to  relieve  the  tedium 
of  confinement,  and  to  occupy  his  mind.  At  a  later  period,  and  where  no 
positive  reason  to  the  contrary  exists,  if  he  be  a  smoker,  he  maybe  permitted 
his  cigar  or  pipe.  Growing  flowers  and  plants  in  the  chamber  have  been 
objected  to  on  the  ground  of  their  tendency  to  absorb  oxygen  and  give  off 
carbonic  acid.  Bui  practically  this  is  an  error,  for  in  fact  the  plant  lives  on 
carbonic  acid,  and  during  daylight,  while  its  nutrition  is  going  on,  carbonic 
acid  in  large  quantities   is  absorbed  and  oxygen  given  off.     At  night  the 


TRAUMATIC    OR    SURGICAL    FEVER.  455 

nutrition  of  the  plant  is  suspended,  and  the  reverse  process  takes  place  in  the 
exercise  of  its  function  of  respiration,  oxygen  being  absorbed  and  carbonic 
acid  being  given  otf,  but  in  quantities  so  small  as  scarcely  to  demand  con- 
sideration. There  is,  therefore,  from  a  chemical  point  of  view,  no  question 
as  to  the  propriety  of  having  living  plants  and  flowers  in  moderation  in  a 
sick  room,  if  proper  ventilation  of  the  latter  be  looked  to.  JEsthetically 
considered,  nothing  can  be  more  delightful  and  cheering  to  a  convalescent 
than  their  presence,  since  they  are  always  lovely  in  themselves,  and  doubly 
so  in  their  happy  influence  on  a  sick  man's  mind. 


Traumatic  or  Surgical  Fever. 

After  most  operations,  especially  if  they  be  of  any  magnitude,  the  patient 
suffers  from  more  or  less  febrile  disturbance.  This  is  known  as  surgical  or 
traumatic  fever,  and  generally  makes  its  appearance  a  few  hours  after  the 
operation,  or  during  the  ensuing  night,  or  on  the  following  day.  It  varies 
greatly  in  intensity;  at  times  it  is  very  slight,  and  at  times  sharply  charac- 
terized from  its  inception.  The  patient  is  at  first  restless  and  uneasy,  tosses 
about,  and  complains  of  heat  and  thirst,  with  more  or  less  headache  ;  the  face 
flushes  at  times  greatl}-,  the  pulse  is  quick  and  tense,  the  skin  feels  hot  and 
dry,  there  is  no  appetite,  but  much  thirst,  and  the  tongue  becomes  dry  and 
furred.  If  the  fever  runs  very  high,  there  may  be  some  mental  disturbance  ; 
the  patient  is  a  little  flighty,  and  in  extreme  cases  eVen  delirious.  The  tempera- 
ture of  the  body  is  increased,  and  rises  to  102°  or  103°  Fahr.,  sometimes  to  104°. 
The  secretions  are  disturbed,  the  urine  is  scanty  and  high  colored,  and  there 
is  commouly  a  general  exacerbation  of  all  these  symptoms  in  the  latter  part 
of  the  day,  or  during  the  evening.  In  ordinary  cases  all  these  s3Tnrptoms 
lessen  about  the  third  or  fourth  day,  and  gradually  pass  away ;  their  subsi- 
dence being  marked  by  the  increasing  comfort  of  the  patient  in  every  respect. 
Traumatic  fever  rarely  lasts  more  than  a  week,  and  usually  only  three  or  four 
days  ;  it  often  assumes  a  somewhat  remitting  character.  All  persons  are  not 
equally  liable  to  the  occurrence  of  this  fever,  nor  is  its  violence  always  in 
proportion  to  the  gravity  of  the  operation  or  injury.  As  already  stated,  it 
may  be  altogether  absent ;  in  an  aggravated  form  it  may  follow  the  slightest 
operation.  Malarial  surroundings,  exposure,  intemperance,  mental  disturb- 
ance, and  debilitating  influences  generally,  probably  act  as  predisposing  causes 
to  its  development. 

The  subject  of  traumatic  fever  has  been  carefully  investigated  by  Billroth, 
who,  as  the  result  of  his  observations,  declares  that  this  fever,  like  any  other 
inflammatory  fever,  depends  upon  a  poisoned  state  of  the  blood,  induced  by 
the  absorption  or  passing  of  various  materials  from  the  seat  of  inflammation, 
or  the  surface  of  the  wound.  At  the  same  time,  it  must  be  observed 
that  the  fever  in  question  sometimes  makes  its  appearance  very  early 
after  operation  ;  before,  indeed,  sufficient  time  has  elapsed  to  permit  de- 
composition to  have  taken  place,  which  forms  so  essential  a  part  in  the 
theory  of  blood-poisoning.  It  would,  therefore,  seem  likely  that  the  shock 
of  operation,  the  manipulation  of  the  tissues,  the  nerve  lesions,  the  swell- 
ing and  resulting  tenderness,  have  just  as  much  to  do  with  the  develop- 
ment of  surgical  fever  as  the  more  obscure  causes  which  have  been  adduced. 
Left  to  itself,  this  fever  in  the  vast  majority  of  cases  soon  diminishes,  and,  by 
the  time  suppuration  has  been  fairly  established,  ceases  altogether.  Should 
it  reappear,  it  carries  with  it  the  suggestion  of  fresh  local  mischief,  such  as 
the  formation  of  abscesses,  or  the  extension  of  the  inflammatory  process  to  other 
parts,  neighboring  or  removed — possibilities  which  demand  careful  investiga- 


456  OPERATIVE    SURGERY    IN    GENERAL. 

tion  from  the  surgeon.  The  occurrence  of  rigors,  in  traumatic  fever,  is  not 
common ;  and  in  this  respect  it  differs,  as  in  many  others,  from  the  urethral 
fever  so  often  encountered  after  operations  on  the  urethra  and  bladder. 

The  treatment  of  surgical  fever  hinges  on  the  patient's  special  condition,  and 
must  be  met  by  a  judicious  application  of  well-known  general  principles.  If 
he  be  very  weak,  he  must  be  supported ;  if  he  be  plethoric,  and  the  fever  run 
high,  with  great  increase  of  temperature,  sedative  fever  mixtures  adapted  to 
restore  the  secretions,  with  the  addition  of  a  little  aconite,  can  be  advanta- 
geously exhibited. 


Conditions  Determining  the  Results  of  Operations. 

In  estimating  the  risks  of  operations,  and  in  comparing  the  hazards  of 
those  of  the  past  with  those  of  the  present  day,  it  is  proper  to  consider  the 
advances  which  have  been  brought  about  by  modern  surgery.  An  operation 
has  always  been  regarded  by  the  community  as  little  short  of  a  catastrophe,  even 
under  the  most  favorable  circumstances,  and  certainly  the  operation  of  former 
times  was  appalling  in  its  nature  when  contrasted  with  the  same  operation  as 
now  practised.  For  the  surgical  mind,  it  is  scarcely  possible  to  contemplate 
anything  more  terrible  than  the  amputation  of  a  limb  before  the  discovery  of 
anaesthesia.  All  of  the  attendant  circumstances  were  calculated  to  strike 
terror  to  the  mind  of  the  trembling  patient;  the  mental  anguish  before  being 
placed  upon  the  table  ;  the  horrid  pain  of  the  operation  itself ;  the  loss  of 
blood,  and  shock,  combined,  were  sufficient  to  intimidate  the  bravest,  and 
must  necessarily  have  influenced  in  no  slight  degree  the  issue  of  the  case. 
But  all  these  horrors  have  almost  vanished  since  the  advent  of  anaesthesia, 
hypodermic  medication,  and  the  application  of  Esmarch's  elastic  bandage. 
The  patient  now  possesses  at  least  the  assurance  that  whatever  may  be  the 
surgeon's  duty,  he  himself  will  feel  no  pain ;  that  his  condition  while  under 
the  knife  will  be  one  of  unconsciousness,  and  that  when  he  returns  to  him- 
self, it  will  be  with  but  the  memory  of  a  dream.  It  is  somewhat  difficult  to 
compare  accurately  the  statistics  of  past  operations  with  those  of  the  present 
day.  By  some,  the  risks  of  operations  have  been  regarded  as  increased  rather 
than  decreased  by  the  discovery  of  anaesthesia.  But  it  would  seem  to  be 
scarcely  possible  that  such  in  reality  could  be  the  case.  It  is  certain,  however, 
that  the  number  of  operations  has  greatly  increased  ;  the  surgeon  of  to-day 
dares  to  do  far  more  than  his  predecessor  would  have  been  willing  to  attempt, 
or  indeed  justified  in  attempting.  The  elimination,  too,  of  the  factor  of  pain 
during  operation,  renders  patients  more  willing  to  submit  to  operation  than 
formerly;  while,  again,  it  wTould  seem  as  if  the  causes  demanding  operation 
had  increased  greatly,  not  only  in  number  but  in  gravity.  The  more  ex- 
tended use  of  machinery,  the  high  velocities  at  which  it  is  driven,  the  in- 
creased chances  of  accident  attendant  upon  great  engineering  projects,  the 
altered  means  of  transportation,  the  more  general  use  of  railway  and  street 
cars,  have  all  combined  to  produce  a  large  class  of  the  "  seriously  injured" 
formerly  unknown.  The  shock  of  accidents  resulting  from  all  such  violent 
causes  must  consequently  be  necessarily  augmented.  Granting,  however,  al- 
though not  proven,  that  the  risks  attendant  upon  operation  are  now  increased, 
it  is  but  fair  to  assume  that  these  augmented  dangers,  if  any,  may  be  fairly 
charged,  in  part  at  least,  to  the  changed  pursuits  and  habits  of  men,  rather 
than  to  the  discovery  of  the  blessing  of  anaesthesia. 

Much  lias  been  said  and  written  of  lute  years  concerning  "hospitalism,"  or 
the  gathering  of  large  numbers  of  patients  into  one  building.  Undoubtedly 
the  effects  of  overcrowding  are  in  the  highest  degree  deleterious,  but  it  must 


CONDITIONS    DETERMINING    THE    RESULTS    OF    OPERATIONS.  457 

be  remembered  that,  during  the  last  quarter  of  a  century,  hospital  facilities 
and  accommodations,  the  world  over,  have  been  infinitely  improved  and  ex- 
tended to  meet  the  demands  of  the  growing  influx  of  patients.  Far  more 
attention  has  been  paid  to  the  wants  and  necessities  of  the  latter,  and  more 
thought  and  enlightened  study  have  been  paid  to  ventilation,  drainage,  and 
cleanliness.  The  necessity  of  increased  air  space  has  been  recognized,  the 
pavilion  system  of  wards  has  been  adopted,  and  the  diet  scale  has  been  changed 
for  the  better,  and  in  accordance  with  physiological  teachings.  It  would  thus 
seem  that,  while  the  demands  upon  the  hospital  are  now  greater  and  more 
imperative  than  they  once  were,  at  the  same  time  every  effort  has  been  made 
to  satisfy  these  claims,  and  that  the  present  hygienic  surroundings  of  the  hos- 
pital patient  are  more  favorable  than  they  have  ever  been  before. 

Before  an  operation  is  undertaken,  the  surgeon  should  always  critically  ex- 
amine his  patient,  so  that  he  may  form  a  correct  estimate  of  his  general  apti- 
tude to  undergo  operation,  and  of  the  ability  of  his  constitution  to  sustain  the 
fresh  weight  about  to  be  imposed  upon  it.  This  examination  must  be  con- 
ducted systematically,  and  must  embrace  the  general  condition  of  the  patient's 
system,  his  habits,  and  an  inquiry  into  the  state  of  his  special  organs,  as  to 
whether  the  latter  are,  or  have  been  recently,  diseased.  It  is  not  always  easy 
to  decide  if  a  man  is  or  is  not  a  good  subject  for  operation.  There  are  so 
many  factors  which  enter  into  the  determination  of  this  question,  that  the 
surgeon  is  liable  to  deceive  himself,  or  to  be  deceived,  unless  his  study  of  the 
case  before  him  is  critical  and  thorough.1 

General  Condition  op  the  Patient. — First,  as  to  the  general  constitution 
of  the  patient :  what  is  it  which  makes,  to  use  the  terms  of  the  insurance 
companies,  a  "good  risk"?  Undoubtedly  they  are  the  best  subjects  for  opera- 
tion, in  whom  nutrition  is  most  thoroughly  effected,  in  whom  assimilation  is 
well  performed,  whose  secretions  and  excretory  functions  are  in  perfect  work- 
ing order,  and  in  whom  consequently  there  is  no  organic  disease.  Now  these 
conditions  may  be  found  both  in  fat  and  in  lean  subjects. 

Obesity  is  usually  regarded  as  one  of  the  eontra-indications  to  operation,  but 
it  must  be  remembered  that  many  persons  who  are  in  perfect  health  are  fat, 
and  that  any  undue  falling  off  from  this  state  is  attended  with  more  or  less  loss 
of  health.  On  the  other  hand,  there  are  those  who  are  normally  lean.  Fat  is 
not  in  itself  an  evidence  of  deranged  health,  if  it  be  natural  or  hereditarv ; 
but  excessive  fat,  or  sudden  or  precocious  development  in  this  direction,  must 
be  regarded  as  one  of  the  evidences  of  something  being  amiss  constitutionally ; 
especially  is  this  the  case  if  fatness  be  unaccompanied  by  a  healthy  condition 
of  the  skin  and  capillary  system,  or  if  the  development  have  occurred  sud- 
denly, or  from  habits  of  drinking,  gluttony,  or  indolence,  and  when  the  pa- 
tient is  inert,  and  unwilling  or  incapable  of  taking  proper  exercise,  or  exertion. 
Under  such  circumstances,  the  person  is  apt  to  be  flabby  or  loose  in  his  tis- 
sues; and  there  is  a  want  of  that  firmness  and  contractility  of  the  skin  and 
subjacent  structures  which  is  inseparable  from  health.  This  state  is  not  1  in- 
frequently observed  in  women  approaching  or  passing  middle  a^e,  and,  when 
found,  unquestionably  indicates  that  the  possessor  is  no  longer  in  the  best 
condition  of  health,  nor  well  suited  to  undergo  the  risks  of  a  surgical  opera- 
tion.    In  such  persons,  the  wounds  of  operation  do  not  heal  well ;  there  is 

1  For  an  elaborate  and  exhaustive  study  of  the  risks  of  operations,  and  of  the  causes  influ- 
encing their  results,  the  reader  is  invited  to  consult  the  published  lectures  of  Sir  James  Paget, 
who  has  fully  treated  of  these  subjects  in  paragraphs  which  have  already  become  classical.  So 
great  has  been  his  experience,  so  close  his  observation,  and  so  lucid  the  utterance  of  his  beliefs, 
that  it  seems  as  if  little  else  were  left  for  other  pens  ;  and  the  writer  of  the  present  article  has 
accordingly  not  hesitated  to  make  free  use  of  the  teachings  of  this  eminent  surgeon. 


458  OPERATIVE    SURGERY    IN    GENERAL. 

commonly  much  suppuration  and  burrowing  of  matter,  and  a  tendency  to 
sloughing.  These  conditions  all  predispose  to  exhaustion,  and  to  intercurrent 
diseases  of  a  low  type. 

The  state  of  plethora  which  is  marked  in  those  who  are  usually  spoken  of  as 
"full  blooded,"  is  also  one  which  requires  careful  consideration  from  the  sur- 
geon. If  this  condition  is  confined  simply  to  the  external  surface,  and  is  not 
accompanied  by  internal  congestions,  or  derangement  of  the  viscera,  and  has 
not  been  produced  by  free  living,  there  is  no  reason  why  the  surgeon  should 
refrain  from  operating.  He  must  simply  be  on  his  guard  against  the  devel- 
opment of  intercurrent  affections  of  an  inflammatory  type,  to  which  such  per- 
sons may  possibly  be  naturally  disposed. 

Leanness  is  not  a  bar  to  operation,  uidess  it  result  from  non-nutrition,  de- 
fective assimilation,  or  excessive  excretion,  in  which  case  it  will  probably  be 
found  to  depend  upon  some  perverted  function  or  organic  disturbance.  When 
loss  of  flesh  has  occurred  from  overwork,  or  too  great  mental  or  bodily  strain, 
the  surgeon  should  be  careful,  and,  except  in  urgent  cases,  should  defer  ope- 
ration, if  possible,  until  the  patient  has  by  proper  therapeutic  and  dietetic 
measures  been  brought  to  a  better  grade  of  health.  In  short,  it  may  be  re- 
peated, as  already  stated,  that  when  the  deflections  from  the  standard  of  health 
have  been  produced  by  impaired  nutrition,  or  organic  disease,  the  patient  is 
not,  and  will  not  be,  in  a  suitable  state  for  operation  until  the  exciting  cause 
has  been  remedied  or  removed  to  the  greatest  degree  possible. 

Habits  of  Patient. — Habits,  bad  habits,  play  an  important  part  in  render- 
ing a  patient  unfit  for  operation.  The  evil  effects  of  the  excessive  use  of 
stimulus;  opium  eating;  the  taking  of  chloral  or  other  pernicious  agents  of 
this  kind,  are  so  well  known  as  scarcely  to  demand  more  than  a  passing 
mention.  Drunkenness,  too,  in  its  varied  forms,  is  one  of  the  most  familiar 
examples  of  the  contra-indications  to  operation.  But  here  there  is  a  differ- 
ence of  degree.  The  quiet  drinker,  who  "soaks"  over  night,  and,  while  rarely 
quite  drunk,  seldom  goes  to  bed  really  sober,  is,  perhaps,  one  of  the  worst 
subjects  for  an  operation.  In  his  case  there  is  in  all  probability  more  or  less 
organic  hepatic  trouble,  or,  if  this  condition  is  not  yet  fully  established,  there 
is  a  tendency  in  that  direction.  In  him  the  powers  of  life  are  lowered,  and 
there  is  a  lack  of  that  vital  resistance  necessary  to  carry  him  through  the 
perils  of  an  operation.  In  such  cases,  too,  there  is  always  more  or  less  ten- 
dency to  the  development  of  delirium  tremens,  and,  when  this  occurs,  the 
prognosis  always  becomes  grave.  In  confirmed,  steady  drinkers,  the  outlook 
after  surgical  interference  is  bad,  and  more  so  after  accidents  which  demand 
amputation.  Even  here,  however,  poor  as  the  chances  are,  the  probability  is 
that  primary  amputations  are  less  dangerous  than  secondary— the  latter  when 
of  the  severer  kind  not  unfrequently  ending  fatally. 

There  is  another  class  of  intemperates  upon  whom  the  effects  of  operation 
arc  not  so  disastrous  as  in  the  group  already  referred  to.  These  persons 
indulge  occasionally  in  fits  or  bouts  of  drinking,  the  duration  of  the  debauch 
usually  lasting  from  two  to  six  days.  These  periods  of  carouse  are  succeeded 
by  weeks  or  months  of  sobriety,  during  which  time  the  individual  attends 
to  his  business  actively  and  industriously.  Operations  performed  during 
these  intervals  of  abstinence,  are  not  necessarily  attended  Iry  any  \evy  great 
amount  of  increased  risk  to  life;  nevertheless  the  surgeon  must  watch  care- 
fully against  the  advent  of  untoward  symptoms.  It  .must  also  be  remarked 
that,  in  these  unfortunates,  the  craving  for  drink  is  apt  to  be  developed  at 
times  until  it  assumes  almost  the  form  of  mania.  To  the  practised  eye  the 
approach  of  these  drinking  periods  is  unmistakable,  the  patient's  manner 
being  marked  at  times  by  tits  of  irresolution,  and  at  times  by  a  general  state 


CONDITIONS    DETERMINING    THE    RESULTS    OF    OPERATIONS.  459 

of  exaggeration  and  excitement  of  the  mental  functions — the  sure  forerunners 
of  coming  trouble.  During  and  preceding  these  attacks  no  operation  should 
be  attempted,  unless  in  the  utmost  emergency. 

In  close  relation  to  excess  in  drinking,  stands  overfeeding,  or  gluttony. 
Overindulgence  in  the  pleasures  of  the  table  undoubtedly  adds  to  the  risk  of 
operation,  inasmuch  as  an  abnormal  condition  is  thereby  developed,  accom- 
panied by  bodily  indolence,  and  by  perversion  of  the  natural  excretions.  This 
is  the  case  when  large  amounts  of  meat  are  consumed,  and  when  deficient 
exercise  interferes  with  the  proper  elimination. 

Influence  of  Nervous  System. — There  is  another  class  of  persons  upon 
whom  the  surgeon  at  times  almost  fears  to  operate,  in  consequence  of  the 
existence  of  what  is  ordinarily  described  as  a  "  nervous"  state  of  mind  and 
body.  It  is  possible,  however,  that  fears  in  this  respect  are  often  exaggerated. 
A  patient  may  be  timid  and  nervous  in  the  highest  degree,  with  a  mind 
worked  up  to  a  point  of  greatest  tension ;  his  clread  of  operation  may  be  so 
intense  as  to  give  rise  to  fears  of  subsequent  shock ;  and  yet,  after  all,  the 
operative  dangers  in  such  a  case  may  be  imaginary  rather  than  real.  As 
long  as  organic  disease  does  not  exist,  the  surgeon  may  hope  and  indeed 
count  upon  this  depression,  dependent  upon  mental  causes,  passing  away  as 
soon  as  the  contemplated  operation  has  been  performed.  Here  the  reaction 
is  not,  usually,  as  quick  and  marked  as  was  the  pre-existent  mental  prostra- 
tion, and,  the  depressing  cause  once  removed,  the  patient  will  probably  pass 
to  a  corresponding  condition  of  contentment  of  mind  in  every  way  favorable 
to  the  production  of  a  happy  result. 

Operations  are  often  demanded  upon  feeble  persons  in  whom,  although 
there  are  no  evidences  of  positive  disease,  there  is  an  absence  of  robust  "or 
even  of  moderate  health.  Such  individuals  are  apt  to  have  been  overworked 
or  worried.  They  have  been  taxed  either  mentally  or  bodily  beyond  their 
powers  of  endurance,  and  are  in  no  condition  to  sustain  the  weakening  and 
depressing  effects  of  operation.  In  such  cases,  all  surgical  interference  should, 
if  possible,  be  delayed  until,  by  rest  and  judicious  medical  treatment,  the 
general  condition  has  been  sufficiently  improved. 

As  a  familiar  example  of  the  class  of  patients  first  referred  to — the  men- 
tally overtaxed — may  be  cited  the  hard-worked  man  of  business,  whose  mind 
has  long  been  kept  on  the  strain  by  the  exacting  nature  of  his  calling,  and 
whose  face  betokens  the  anxiety  and  harassment  of  his  vocation.  His  aim 
is  the  accumulation  of  money,  and  for  its  accomplishment  all  other  objects 
must  give  way — even  health  itself.  Of  the  latter  class — those  worked  beyond 
bodily  endurance  and  ill  fed — there  are  in  this  country  fortunately  but  few, 
the  rate  of  wages  being  usually  sufficient  to  provide  good  food  and  a  home 
for  the  poorest  laborer,  if  he  be  industrious. 

Age  and  Sex. — Age  exercises  a  decided  influence  upon  the  results  of  opera- 
tions. As  a  rule  children  bear  operations  well,  and,  while  they  are  peculiarly 
susceptible  to  pain  and  shock,  they  are  not  liable  to  the  mental  depression 
which  acts  so  powerfully  in  after  life.  They  are  usually  healthy,  and  their 
internal  organs  are  not  so  frequently  the  seat  of  organic  diseases,  the  result 
of  long-continued  or  abused  action,  as  those  of  adults.  Their  growing  con- 
dition, moreover,  favors  the  process  of  repair,  and  the  union  of  wounds."  The 
chief  danger  to  them  is  shock,  consequent  upon  pain  and  hemorrhage;  the 
latter  undoubtedly  acts  powerfully  in  this  direction,  but,  this  once  overcome, 
the  wounds  of  children  heal  kindly  and  rapidly,  and  they  are  rarely  sub- 
ject to  the  secondary  complications  of  pyaemia  or  septicaemia ;  tetanus  may 
at  times  occur,  but  more  often  as  the  consequence  of  lacerated  or  ragged 


460  OPERATIVE    SURGERY    IN    GENERAL. 

wounds,  than  of  simple  operations.  Another  important  feature  in  the  favor 
of  children,  as  suhjects  of  operation,  is  the  readiness  and  comparative  comfort 
with  which  they  bear  confinement.  Easily  satisfied  and  amused,  they  soon 
accustom  themselves  to  their  new  condition,  and  pass  through  a  long  period 
of  confinement  to  bed,  possibly  subject  in  the  mean  while  to  exhausting  dis- 
charges, in  a  manner  unknown  to  those  of  more  mature  age. 

The  tendency  of  children  to  suffer  from  the  exanthemata  must  always  be 
remembered,  and  no  operation  should  be  attempted  on  them  when  exposed  to 
these  affections.  There  is  also  in  children,  as  has  been  pointed  out  by  Sir 
James  Paget,  a  special  liability  to  the  occurrence  of  scarlatina  after  operation. 
Why  this  should  be  so,  is  not  clear,  but  it  seems  probable  that  the  shock  of 
operation  upon  children  carries  with  it  a  predisposition  to  the  development  of 
this  disease,  especially  if  it  is  epidemic  at  the  time.  The  same  writer  also 
states  that  the  type  of  the  disease,  occurring  under  these  circumstances,  is 
somewhat  modified,  and  the  period  of  incubation  shortened.  In  some  chil- 
dren the  disease  appears  on  the  whole  surface  at  once ;  in  others,  more  deci- 
dedly upon  the  limbs ;  sore  throat  and  desquamation  are  observed  in  some, 
and  not  in  others.  The  development  of  this  affection  necessarily  adds  to  the 
hazard  of  operations  in  childhood. 

The  performance  of  certain  operations  upon  children  is  at  times  difficult, 
and  demands  a  high  degree  of  anatomical  knowledge,  in  consequence  of  the 
contracted  space  in  which  procedures,  often  of  a  delicate  and  complicated 
nature,  must  be  practised.  Yet,  as  a  rule,  the  average  child  may  be  regarded 
as  a  good  subject  for  operation,  and  in  this  respect  contrasts  strongly  with 
persons  of  advanced  age.  In  the  latter,  the  powers  of  life  are  already  weak- 
ened, and  it  requires  but  little  to  disturb  the  vital  equilibrium.  The  chances 
of  the  existence  of  organic  disease  in  one  or  more  of  the  great  viscera,  and,  in 
men  particularly,  in  the  genito-urinary  organs,  must  be  considered.  No  surgeon 
would  deliberately  select  a  very  old  man  as  the  subject  for  operation,  and  yet 
in  many  instances  such  patients  will  recover  from  operations  wonderfully 
well.  Still,  this  cannot  be  anticipated,  and  must  be  looked  upon  as  an  ex- 
ceptional circumstance.  Age  cannot  always  be  measured  by  years  alone  ;  a 
good  deal  depends  upon  the  constitution,  and  upon  pre-existent  habits,  and  they 
have  the  best  chances  of  recovery  who  are  in  the  best  general  condition  of 
health.  When  operations  are  called  for  upon  the  aged,  every  effort  should 
be  made  to  prevent  hemorrhage  and  shock,  and  such  patients  should  not  be 
kept  in  bed  longer  than  is  absolutely  necessary.  All  depleting  measures 
should  be  carefully  avoided,  and  the  diet  should  be  of  the  most  nourishing, 
and,  if  necessary,  stimulating  kind. 

Sex. — As  far  as  sex  is  concerned,  there  does  not  seem  to  be  a  great  deal  of 
difference  as  to  the  capacity  of  men  and  women  to  sustain  operations.  The 
latter  are  undoubtedly  more  patient,  more  accustomed  to  endure  suffering,  and 
more  tolerant  of  confinement  to  house  and  bed.  At  the  same  time,  there  are 
certain  physiological  conditions  of  womanhood  which  must  be  borne  in  mind 
in  the  selection  of  the  time  of  operation.  Thus  the  menstrual  period  should 
be  avoided.  The  woman  is  then  in  a  state  of  nervous  irritability,  and  often 
of  positive  pain.  Her  mental  and  physical  functions  are  in  a  degree  perverted, 
and  her  judgment  and  self-control  disturbed.  In  fact,  she  is  not  then  in  a 
state  to  l)e  exposed  to  any  increased  or  unnecessary  irritation.  The  best 
period  for  operation  in  women  is  probably  from  five  to  eight  days  after  the 
cessation  of  the  menstrual  How.  After  operation,  it  frequently  happens  that 
the  menses  will  make  their  appearance  too  soon,  and  in  anticipation  of  the 
proper  period;  and  the  nearer  to  the  latter  that  the  operation  is  performed, 
the  more  apt  is  this  anticipation  to  occur. 


CONDITIONS    DETERMINING    THE    RESULTS    OF    OPERATIONS.  461 

Operations  during  pregnancy  should  be  avoided  when  it  is  possible." 
Sometimes  this  cannot  be  done,  the  conditions  demanding  surgical  interfer- 
ence being  imperative.  When  such  is  the  case,  every  precaution  should  be 
taken  to  guard  against  excessive  nervous  disturbance,  and  the  risks  of  mis- 
carriage. It  must  here  be  observed  that  when  wounds  and  accidents  do  occur 
during  gestation,  the  healing  and  reparative  processes  are  usually  very  rapid. 
During  lactation,  operations  should  also  be  avoided,  as  prejudicial  alike  to 
mother  and  child  ;  nor  should  surgical  interference  with  the  mammary  gland 
be  needlessly  undertaken.  Tumors  in  this  region  should  never  be  removed 
at  that  time,  as  much  on  account  of  the  probable  hemorrhage,  as  for  other 
reasons. 

Race  and  Temperament. — The  influence  of  race  is  potent  in  determining 
the  results  of  operations.  Strange  as  it  may  seem,  the  black  races  and  the 
Oriental  nations  sustain  injuries  and  operations  best ;  next  stand  the  Anglo- 
Saxons  ;  and,  according  to  M.  Chauffard,  the  Latin  race  is  as  far  behind  them 
as  they  are  behind  the  black  race.  The  immunity  of  the  Chinese  and  Japa- 
nese to  mortality  after  operations  is  remarkably  shown  by  the  various  reports  of 
medical  officers  serving  in  the  East.  It  is  stated  that  pyaemia  is  a  rare  occur- 
rence among  the  Chinese,  and  in  a  recent  report  of  138  operations  for  lithotomy 
performed  on  persons  of  all  ages  and  occupations,  from  two  years  old  to 
eighty,  but  eight  deaths  occurred.1  A  similar  immunity  is  said  to  be  enjoyed 
by  the  Japanese  in  regard  to  pyaemia,  septicaemia,  tetanus,  and  erysipelas.  It 
is  difficult  to  understand  why  this  should  be,  unless  the  explanation  is  to  be 
found  in  the  fact  that  the  lower  classes  of  these  races  live  chiefly  on  vegetable 
diet  and  fish,  and  eat  but  little  meat. 

In  our  own  country,  the  negro  has  generally  borne  injuries  and  operations 
well,  provided  that  he  has  not  been  exposed  to  the  after  vicissitudes  of  cold 
and  dampness.  This  was  remarkably  shown  in  the  experience  of  the  negro 
brigades  during  the  late  American  war.  According  to  the  observation  of  the 
writer,  when  these  soldiers,  injured  in  battle,  were  cooped  up  in  overcrowded 
and  overheated  hospitals,  they  did  well ;  when,  however,  removed  to  well- 
ventilated  pavilion  hospitals,  and  placed  under  such  hygienic  conditions  as 
are  most  favorable  to  the  white  American  soldier,  they  did  badly,  suffering 
severely  from  intercurrent  pulmonic  and  other  acute  inflammations.  In  the 
daily  practice  of  our  hospitals,  the  negro  is,  we  think,  regarded  as  a  satisfac- 
tory patient,  and  one  of  whose  case  a  favorable  prognosis  can  usually  be 
formed.  Whether  this  be  due  to  the  happy  mental  condition  of  his  race,  and 
to  its  characteristic  freedom  from  care,  cannot  perhaps  be  clearly  shown. 

The  Irish,  from  their  peculiar  mental  elasticity,  also  bear  operations 
well,  and  so  do  the  more  phlegmatic  Germans.  The  American  is  not  so  good 
a  patient ;  his  activity  of  mind  renders  him  restless  and  impatient  of  restraint ; 
he  looks  anxiously  forward  to  the  end  of  his  convalescence,  and  not  infre- 
quently ventures  out  of  doors  too  soon,  and  thus  hinders  his  own  recovery. 

The  influence  of  personal  temperament  is  not  less  than  that  of  race.  A 
happy  and  contented  disposition  contributes  greatly  to  convalescence  after 
operation,  for  it  enables  the  patient  to  obtain  and  enjoy  that  rest  of  body  as 
well  as  of  mind  which  has  so  much  to  do  in  bringing  about  recovery. 

Influence  of  the  Seasons  and  Weather  on  Operations. — The  popular  as 
well  as  the  professional  mind  has  long  since  recognized  the  influence  of  the 
weather  on  certain  general  and  local  conditions  of  the  body.     Its  effects  upon 

1  Imperial  Maritime  Customs.     Medical  Reports,  187S-9. 


462  OPERATIVE    SURGERY    IN    GENERAL. 

•rheumatism,  neuralgia,  diseased  bones,  and  the  ends  of  stumps,  are  examples 
in  point.  But,  strange  to  say,  its  precise  relations  to  surgical  operations,  and 
the  influence  it  exerts  upon  their  results,  had  never,  as  far  as  we  know,  re- 
ceived that  precise  study  which  they  deserved,  until  the  year  1869,  when  Dr. 
Addinell  Hewson,  of  Philadelphia,  published  in  the  Pennsylvania  Hospital 
Reports  for  that  year,  a  paper  on  the  "  Influence  of  Weather  on  the  Results 
of  Surgical  Operations."  This  was  followed,  in  1870,  by  the  published  lec- 
tures of  Dr.  Richardson,  of  London,  in  the  Medical  Times  and  Gazette  for 
January  and  February  of  that  year.  The  observations  of  these  two  investi- 
gators agree  in  the  main,  and  may  be  thus  epitomized.  It  must  here  be  stated 
that  by  "the  weather"  is  meant  the  measure  of  the  changes  of  the  conditions  of 
the  temperature,  humidity,  and  pressure  of  our  atmosphere,  relatively  to  each 
other.  Dr.  Ilewson's  deductions  are  based  upon  the  observation  of  259  ope- 
rations performed  at  the  Pennsylvania  Hospital  in  the  thirty  years  preceding 
1860,  during  which  period  a  meteorological  register  had  been  faithfully  kept 
by  Dr.  Conrad,  the  apothecary.  Taking,  as  the  expression  of  the  changing 
weather,  the  barometrical  condition,  and  regarding  it  as  ascending,  stationary, 
and  descending,  Dr.  Hewson  found  that,  of  the  259  operations,  102  were  per- 
formed when  the  barometer  was  ascending,  91  patients  recovering  and  11 
dying,  giving  a  death-rate,  of  10.7  per  cent.;  34  operations  were  performed 
when  the  barometer  was  stationary,  giving  26  recoveries  and  8  deaths,  a  mor- 
tality of  20.6  per  cent. ;  and  123  operations  were  practised  when  the  barometer 
was  descending,  with  88  recoveries  and  35  deaths,  a  mortality  of  28.4  per  cent. 
In  other  words,  with  an  ascending  barometer  the  mortality  of  operations  was 
a  little  less  than  eleven  per  cent.,  with  a  stationaiy  barometer  more  than 
twenty  per  cent,  and  with  a  descending  barometer  more  than  twenty -eight 
per  cent.  In  the  same  general  way,  it  was  observed  that  the  results  of  opera- 
tions were  most  favorable  in  autumn  and  winter,  and  least,  so  in  summer.  The 
most  happy  month  for  operating  was  October,  then  January,  then  April. 
The  frequency  and  mortality  of  pyremia  bore  a  direct  relation  to  low  baro- 
metrical pressure  and  moisture  of  air,  while  the  deaths  from  shock  occurred 
in  a  constant  ratio  with  the  opposite  condition,  dryness  of  weather. 

The  deductions  of  Dr.  Richardson  tend  strongly  in  the  same  direction,  for 
he  finds  that  the  most  favorable  time  for  operating  is  when  the  barometer  is 
steadily  rising  or  steadily  high  ;  when  the  wet  bulb  thermometer  shows  a 
reading  of  five  degrees  lower  than  the  dry  bulb;  and  when,  with  a  high  baro- 
meter, and  a  difference  of  five  degrees  in  the  two  thermometers,  there  is  a  mean 
temperature  at  or  above  55°  Fahr.  On  the  other  hand,  the  time  is  unfavorable 
for  operations  when  the  barometer  is  steadily  falling,  or  steadily  low;  when 
the  wet  bulb  thermometer  approaches  the  dry  bulb  within  two  or  three  de- 
grees; and  when,  with  a  low  barometrical  pressure,  and  approach  to  unity  of 
reading  of  the  two  thermometers,  there  is  a  mean  temperature  above  45°,  and 
under  55°  Fahr. 

Such  arc  the  results  of  precise  observation,  and  they  seem  to  accord  with 
the  general  empirical  idea  that  large  operations  should  not  be  unnecessarily 
performed  in  very  warm  weather — at  all  events  in  the  height  of  an  Ameri- 
can  summer,  when  the  thermometer  frequently  ranges  from  90°  to  100°  in 
the  shade.  We  all  know  that  at  such  times  a  certain  degree  of  lassitude  is 
felt  by  every  one;  and  it  would  seem  reasonable  that  the  eombined  influence 
of  intolerably  warm  days  and  breezeless  sultry  nights,  must  be  to  weaken  the 
constitution  temporarily,  and  to  deprive  it  for  the  time  being  of  those  powers 
<>f  resi stance  which  are  so  essential  to  speedy  convalescence  after  operation. 
It  is  not  likely,  as  is  commonly  supposed,  that  wounds  heal  less  kindly  in  warm 
weather,  but  it  is  certain  that  debilitation  from  any  cause  docs  seriously  inter- 
fere with  the  general  recuperative  powers,  and  the  main  consideration  alter 


CONDITIONS    DETERMINING    THE    RESULTS    OF    OPERATIONS.  463 

operation  is  the  patient's  strength.  From  what  has  been  said,  it  will  be  seen 
that  the  season  has  not  as  much  to  do  with  operation  as  the  weather,  and  in 
this  relation  the  tendency  to  intercurrent  diseases  must  be  borne  in  mind. 
During  the  winter,  these  are  most  apt  to  involve  the  pulmonary  organs,  in 
the  forms  of  acute  bronchitis  and  pneumonia,  while  in  the  summer,  the  abdo- 
minal viscera  suffer  from  the  acute  internal  inflammations,  accompanied  by 
diarrhoea. 

Locality  has  something  to  do  with  the  result  of  operations.  "When  the 
patient  is  exposed  to  damp  and  depressing  exhalations,  and  to  malarious  in- 
fluences, wounds  do  badly,  and  convalescence,  particularly  after  the  lar^e 
operations,  is  tardy.  The  reverse  is  the  case  when  the  atmosphere  is  dry  and 
exhilarating,  as  on  the  mountain  slopes.  The  sea  breezes  also  act  as  a  most 
powerful  tonic.  It  would  be  easy,  from  the  recent  military  experiences 
of  our  country,  to  adduce  example  after  example  in  support  of  these  asser- 
tions. It  has  often  happened  that,  after  great  battles,  soldiers  who  had  under- 
gone amputations  and  other  severe  operations,  have  from  military  exigencies 
been  left  for  a  time  in  field  hospitals,  planted  in  unhealthy  districts,  and 
swept  by  marsh  exhalations.  Under  such  circumstances,  wounds  and  stumps 
not  unfrequently  did  badly,  and  assumed  a  sloughing  and  unhealthy  appear- 
ance. As  soon,  however,  as  the  men  could  be  removed  to  hospitals  in  salu- 
brious localities,  an  immediate  change  in  their  condition  was  observed.  The 
wounds  cast  off  their  unhealthy  character,  and  entered  upon  active  repara- 
tion. No  operation  should  be  performed,  except  in  cases  of  emergency,  in  any 
locality  in  which  an  epidemic  is  prevailing,  such  as  diphtheria,  erysipelas, 
cholera,  yellow  fever,  and  possibly  influenza  of  a  bad  type. 

Influence  of  Visceral  Affections. — There  are  certain  organic  diseases  of 
the  great  viscera  which  exert  a  direct  and  unfavorable  bearing  upon  the 
chances  of  operation.  Chief  among  these  are  affections  of  the  heart,  lungs, 
and  kidney. 

Heart  and  Arteries. — In  regard  to  the  heart,  it  is  probable  that  the  risks 
of  operation  are  not  always  so  seriously  increased  by  disease  of  this  organ 
as  is  generally  supposed.  A  great  deal  will  depend  upon  the  degree  of 
cardiac  trouble,  the  evil  consequences  which  have  attended  it,  or  are  present 
at  the  time,  and  its  duration.  It  not  unfrequently  happens  that  cardiac  dis- 
turbance dependent  upon  valvular  changes  is  relieved  by  the  hemorrhage 
which  attends  an  operation.  If  the  amount  of  disease  observable  is  such  as  to 
greatly  disturb  the  patient,  and  to  interfere  with  his  circulation  and  respira- 
tion, the  risks  of  shock,  either  at  the  time  of  operation  or  subsequently,  must 
undoubtedly  be  recognized.  Fatty  degeneration  of  the  substance  of  the  heart 
is  attended  by  great  danger,  greater  probably  than  the  more  simple  degrees 
of  valvular  obstruction.  These  constitute  the  class  of  feeble  hearts,  which  are 
strongly  influenced  by  shock  and  blood  loss;  and  to  patients  thus  affected, 
ether  should  be  given  in  preference  to  chloroform  on  account  of  its  stimulating 
effects. 

Sir  James  Paget,  in  his  lectures  on  the  risks  of  operations,  has  drawn  atten- 
tion to  the  manner  of  the  heart's  action  when  it  is  believed  to  be  healthy,  and 
to  the  phenomena  of  the  pulse.  lie  tells  us  that  a  slow  pulse  does  not  forbid 
operation^  nor  does  an  accelerated  one  necessarily  do  so,  provided  it  be  not 
accompanied  by  organic  disease.  Children  and  young  persons  of  nervous 
temperament  have  often  very  rapid  pulses,  and  the  surgeon,  in  deciding  upon 
the  propriety  of  operation  upon  them, should  be  guided, not  by  the  pulse  alone, 
but  rather  by  noting  whether  the  respirations  are  proportionately  rapid.     In 


464  OPERATIVE   SURGERY   IN   GENERAL. 

some  persons,  a  pulse  may  beat  120  or  140  in  a  minute,  and  yet  indicate'  no 
trouble  if  the  respiration  do  not  exceed  20  or  25.  The  same  condition  may 
be  observed  in  some  old  persons,  who  may  still  be  good  subjects  for  operation. 
This  plan  of  checking  the  pulse  by  the  respiration  is  also  to  be  followed  in 
cases  of  individuals  recovering  from  sharp  hemorrhages,  when  the  pulse  is 
often  quickened,  while  the  respiration  is  proportionately  slower.  Habitual 
irregularity  of  the  pulse,  not  accompattted  by  valvular  changes  or  degeneration 
of  the  heart  tissue,  need  not  be  seriously  feared  in  estimating  the  chances  of 
operation. 

In  giving  due  weight,  however,  to  the  effect  of  organic  cardiac  disease,  it 
must  be  remembered"  that,  in  addition  to  its  immediate  influence,  it  is  often 
indicative  of  grave  changes  in  other  portions  of  the  system,  and  notably  in 
the  arteries.  "Thus  aneurism  may  be  present,  or  degenerations  in  the  arterial 
walls,  which  may  forbid  or  modify  the  performance  of  an  operation.  Arte- 
rial degeneration,  not  in  itself  a  matter  of  great  importance  in  minor  opera- 
tions, or  in  those  upon  the  face  or  trunk,  becomes  a  serious  affair  in  amputa- 
tions, and  in  the  ligations  of  large  vessels.  Not  only  does  this  condition  favor 
secondary  hemorrhage,  but  it  also  predisposes  to  defective  reparation  and 
extensive  sloughing.  Indeed,  it  is  one  of  the  causes  which  produce  the  high 
rate  of  mortality  after  amputation  of  the  lower  extremities  in  old  persons. 

Lungs. — The  question  of  operating  when  there  is  coincident  disease  of  the 
lungs,  is  one  of  the  gravest  questions  which  can  be  presented  to  the  considera- 
tion of  the  surgeon,  and,  unfortunately,  it  is  one  of  everyday  occurrence.  I)u-  ■ 
ring  acute  inflammation  of  these  organs,  of  course  there  can  be  no  hesitation 
as  to  the  proper  course.  No  operation  should  be  then  performed  unless  for 
the  most  exceptional  and  urgent  causes.  Interference  with  the  pulmonary 
circulation  is  too  serious  a  matter  to  be  lightly  encountered  after  operation, 
and  the  inconveniences  incident  to  a  forced  position,  difficulty  of  breathing, 
and  the  rack  of  coughing  and  expectoration,  must  necessarily  exert  a  harmful 
influence,  locally  as  well  as  constitutionally,  upon  the  issue  of  any  surgical 
operation  demanding  quiet  and  rest.  The  matter,  howTever,  assumes  a  different 
aspect  if  tuberculosis  is  present;  when  the  patient  is  suffering  from  phthisis, 
and  at  the  same  time  from  some  other  ailment  or  casualty  necessitating  sur- 
gical interference.  If  he  has  received  an  injury  or  compound  fracture,  de- 
manding amputation,  there  can  be  no  hesitation.  His  only  salvation  may  lie 
in  the  amputation  of  the  limb,  and  the  condition  of  his  lungs  has,  for  the 
time,  nothing  to  do  with  the  decision  as  to  the  propriety  of  operation.  It 
may  affect  his  after  chances,  but  the  necessity  of  the  case  demands  that  he 
shall  run  this  risk,  and  there  is  no  alternative.  The  case  is  far  different, 
however,  when  the  operation  to  be  decided  upon  is  one  of  expediency,  rather 
than  of  absolute  pressing  necessity,  as,  for  example,  the  removal  of  a  tumor 
or  hemorrhoid,  the  amputation  of  a  limb  for  a  scrofulous  bone  or  joint,  or  the 
division  of  a  fistula.  The  operation  in  these  instances  is  one  which  in  ordi- 
nary states  of  the  system  is  highly  proper,  and  which  ought  to  be  done.  Is 
it  right  to  attempt  it  upon  a  phthisical  patient? 

The  answer  to  this  question  is  not  in  reality  as  difficult  as  it  seems  at  first 
siudit ,  and  is  based  upon  a  careful  balancing  of  the  patient's  chances  of  comfort 
and  life.  In  the  first  place,  the  surgeon  ought  to  make  a  thorough  examina- 
tion, physical  and  otherwise,  of  the  condition  of  his  patient,  in  order  to  deter- 
mine whether  the  phthisis  is,  in  Paget's  words,  "active,  acute,  and  progres- 
sive," or  "passive,  chronic,  and.  suspended."  If  it  be  the  former,  no  operation 
of  magnitude  should  be  attempted,  since  the  course  of  the  disease  would  be 
probably  hastened,  and  the  patient's  life  shortened  by  the  shock  of  operation, 
the  subsequent  febrile  disturbance,  and  the  possible  establishment  of  a  second 


CONDITIONS    DETERMINING    THE    RESULTS    OF    OPERATIONS.  465 

source  of  discharge  and  constitutional  drain.  If,  on  the  other  hand,  the  dis- 
ease of  the  lung  has  been  of  long  continuance,  but  is  now  quiet,  and  is  not 
making  active  progress,  there  is  really  no  reason  why  an  operation,  if  necessary, 
should  not  be  resorted  to.  Yet  it  must  be  quite  clear  to  the  surgeon,  that  the 
proposed  operation  will  make  less  demand  upon  the  strength  of  the  patient, 
than  the  cause  for  which  it  is  performed  is  already  doing.  Thus  it  would 
unquestionably  be  proper  to  remove  a  limb  for  a  suppurating  joint  or  diseased 
bone,  whatever  the  cause  of  the  lesion  might  be,  if  it  were  quite  evident  that 
the  patient's  vital  powers  were  giving  way  under  the  exhausting  drain.  It  not 
unfrequently  happens  that  both  loeal  and  constitutional  evidences  of  scrofu- 
losis  or  tuberculosis  exist  in  the  same  person,  the  deposit  in  the  lung  being 
accompanied  by  a  disorganized  joint.  The  propriety  of  amputation  here  de- 
pends upon  the  precise  pulmonary  condition.  If  the  phthisis  be  far  advanced, 
and  the  lung  already  breaking  down,  operation  is  usually  inadmissible;  but 
if  the  lung  be  as  yet  but  slightly  affected,  there  is  always  the  possibility  that 
its  condition  may  be  improved  by  the  removal  of  the  source  of  local  irritation. 
It  is  well  known  that  JisUda-in-ano  frequently  occurs  in  phthisical  patients. 
By  most  of  the  surgeons  of  a  past  generation,  and  indeed  by  many  of  the 
present  day,  the  existence  of  anal  fistula  was  and  is  regarded  as  rather  favor- 
able to  the  patient  than  otherwise,  it  being  held  that  it  acts  as  a  derivative, 
diminishing  the  progressive  development  of  pulmonary  tuberculosis.  Of  late 
years,  this  opinion  has  been  challenged,  and  there  are  not  a  few,  including 
many  of  the  most  learned  and  practical  pathologists  of  the  present  day,  who 
believe  that  the  reverse  is  the  case  ;  and  the  belief  is  gaining  ground  that  the 
fistula  acts  as  a  supplementary  weakening  discharge,  rather  than  as  a  revulsive. 
The  propriety  of  operation  in  sueh  cases  follows  as  a  matter  of  course,  with 
the  proviso  that  the  attempt  to  cure  fistula?  occurring  in  phthisical  patients 
must  be  restricted  absolutely  to  those  in  whom  the  disease  is  incipient,  or  at 
all  events  not  progressive.  Here,  as  in  other  instances  of  tuberculous  and 
strumous  affections,  it  would  then  seem  proper  to  attempt  the  cure  of  the  affec- 
tion by  operation,  remembering,  however,  that  in  all  sueh  cases  there  is  an 
indisposition  to  healthy  granulation,  and  that  the  wished-for  cure  may  not 
always  be  accomplished.  Dr.  Van  Buren,  in  his  excellent  treatise  on  diseases 
of  the  rectum,  expresses  himself  strongly  on  this  matter.  He  says  that  while 
no  judicious  surgeon  would  operate  for  fistula  upon  a  patient  with  advanced 
cardiac  disease,  or  with  cirrhosis  of  the  liver,  Bright's  disease,  or  cancer,  yet 
in  pulmonary  disease  the  tendency  of  opinion  is  becoming  more  favorable 
to  well-considered  operative  interference.     He  adds : — 

"On  the  following  points  I  do  not  hesitate  to  speak  positively:  there  is  no  reliable 
evidence  that  the  suppression  of  an  habitual  discharge  can  do  any  harm  in  these  cases; 
on  the  contrary,  it  is  pretty  certainly  a  positive  advantage  to  arrest  it;  and  I  would 
advise  the  attempt  to  cure  a  fistula  in  a  patient  with  physical  signs  of  phthisis,  pro- 
vided there  were  no  positively  advancing  softening,  or  severe  cough,  because,  in  addition 
to  stopping  a  waste,  it  would  remove  an  impediment  to  exercise  in  the  open  air,  possi- 
bly on  horseback.  The  objections  to  operating  where  there  is  softening  or  hectic  an*, 
that  the  concussion  from  coughing,  and  the  lack  of  power,  might  prevent  the  wound 
from  healing,- and  that  the  use  of  the  knife  would  necessitate  confinement  to  bed,  and 
thus  injure  the  patient." 

In  all  operations  which  the  surgeon  may  attempt  on  phthisical  or  scrofu- 
lous patients,  he  must,  as  Paget  has  advised,  carefully  avoid  keeping  them  too 
long  in  one  atmosphere,  lest  he  may  bring  about  that  gradual  impairment  of 
health  which  is  so  favorable  to  the  progress  of  tubercular  disease. 

Urinary    Organs. — The   results   of  operations  and  of  injuries   are   more 
powerfully  influenced  by  organic  disease  of  the  kidney  than  by  that  of  any 
vol.  :.— 30 


466  OPERATIVE    SURGERY    IN    GENERAL. 

other  organ.  In  health,  the  kidney  would  seem  to  exercise  less  influence 
upon  life  than  the  heart  or  liver ;  yet  after  traumatism,  the  recovery  of  the 
patient  often  depends  upon  the  manner  in  which  the  kidneys  are  acting.  The 
function  of  these  organs  is  essentially  one  of  elimination  and  blood  purifica- 
tion, and  upon  their  perfect  working,  the  excretion  from  the  blood  of  noxious 
elements  to  a  large  extent  depends.  An  impaired  kidney,  which  has  under- 
gone certain  pathological  changes,  and  which  may  be  secreting  urine  contain- 
ing albumen  or  sugar,  or  failing  to  excrete  the  usual  amount  of  normal  uri- 
nary products,  may  suffice  for  a  while  for  the  support  of  life,  provided  that 
no  extra  strain  be  put  upon  it.  It  is,  however,  an  organ  of  a  delicate  and 
sympathizing  nature,  and  is  peculiarly  susceptible  to  the  shock  of  operation — 
indeed  marvellously  so,  when  the  genito-urinary  organs  are  concerned.  The 
slightest  disturbance  often  serves  to  modify  and  arrest  its  secretion,  to  such 
an  extent  as  to  give  rise  to  fatal  consequences.  A  careful  examination  of  the 
urine  should  therefore  invariably  be  made  before  any  operation  of  magnitude 
is  attempted,  and,  if  necessary,  this  examination  should  be  repeated  at  inter- 
vals. The  steady  presence  of  albumen,  not  dependent  on  febrile  causes  or 
mechanical  impediment,  especially  if  accompanied  by  renal  casts,  reveals  the 
story  of  a  kidney  organically  changed.  Here  all  operation  must  be  refrained 
from  if  possible,  or,  if  imperatively  demanded,  the  increased  attendant  dan- 
gers must  be  looked  steadily  in  the  face.  The  clinical  import  of  albuminuria 
is  familiar  to  every  one,  as  indicating  a  tendency  to  the  development  of  in- 
flammations of  the  serous  membranes,  and  of  some  of  the  viscera. 

Two  difficulties  are  met  with  in  forming  a  diagnosis  of  renal  affections. 
The  first  of  these  is  the  existence  of  disease  in  the  bladder,  attended  by  the 
formation  of  pus  and  albumen,  and  their  collateral  products.  The  second  is 
the  occurrence  of  chronic  disease  in  the  ureter,  leading  to  its  closure  by 
thickening  of  its  walls,  or  by  the  choking  of  its  canal  dependent  upon  the 
inspissation  or  hardening  of  inflammatory  products.  In  each  of  these  condi- 
tions the  functions  of  the  kidney  are  deranged,  its  secretion  is  interfered  with, 
and  a  corresponding  extra  amount  of  work  is  imposed  upon  its  fellow. 
When  cystitis  is  present,  it  is  absolutely  impossible  to  form  any  idea  of  the  man- 
ner in  which  the  duties  of  the  kidneys  are  being  discharged.  When  ordinary 
desquamative  nephritis — Bright's  disease — is  developed,  it  is  always  attended 
by  oedema,  dropsies,  and  other  familiar  symptoms.  The  contracting  kidney  is 
marked  by  intermittent  albuminuria,  and  by  the  presence  of  renal  casts.  It  is, 
however,  an  affection  which  progresses  slowly,  and  its  symptoms  are  at  times 
obscure.  Clinically  speaking,  the  dangers  of  operations  in  this  form  of  kidney 
are  greater  than  in  the  ordinary  form  of  Bright's  disease.  Renal  congestion, 
accompanied  by  alteration  or  suppression  of  secretion,  not  unfrequently  follows 
the  simplest  surgical  procedures,  such  as  catheterism,  or  the  dilatation  of  a 
stricture.  Its  occurrence  portends  new  and  alarming  danger  for  the  patient, 
and  it  is  therefore  not  improbable,  as  has  been  suggested  by  Mr.  Reginald 
Harrison,  that  this  is  just  the  state  so  often  productive  of  surgical  calamities, 
the  causes  of  which  are  puzzling,  and  apparently  difficult  of  explanation. 

Pyelitis,  or  suppurating  kidney,  often  spoken  of  as  the  "surgical  kidney," 
is  frequently  observed  by  the  surgeon.  In  this  disease  the  renal  pelvis  and 
calyces  are  inflamed  and  suppurating.  The  inflammatory  action  may  extend 
into  the  secreting  portion  of  the  kidney,  and,  when  pus  is  formed  in  quantity, 
we  not  unfrequently  find  after  death  that  the  ureter  has  been  largely  involved, 
sometimes  presenting  sacculi  of  considerable  size,  filled  with  purulent  fluid. 
Viewing  the  very  decided  post-mortem  appearances,  it  might  be  supposed 
that  this  condition  could  always  be  detected  during  life.  Unfortunately  its 
existence  is  often,  perhaps  most  often,  coincident  with  chronic  vesical  or  pro- 
static disease,  and    the    symptoms  of  its  occurrence  are  therefore  to  some 


CONDITIONS    DETERMINING    THE    RESULTS    OF    OPERATIONS.  467 

decree  masked,  and  at  times  difficult  of  recognition.  It  need  scarcely  be  said 
that  such  a  state  of  affairs  bears  terribly  on  the  chances  of  operation.  A  kid- 
ney thus  damaged,  and  forming  pus,  is  unable  to  discharge  its  duties  under 
ordinary  circumstances  ;  and  certainly  not  when  subjected  to  the  shock  and 
increased  irritation  produced  by  urethral  and  vesical  operations. 

Disease  of  the  bladder  also,  like  disease  of  the  kidney,  with  which  it  is 
usually  associated,  exerts  a  most  unhappy  effect  upon  the  issue  of  operations, 
especially  when  it  is  chronic,  or  occurs  in  old  persons. 

The  occurrence  of  sugar  in  the  urine  is  not  a  whit  less  serious  than  albumi- 
nuria, and,  if  the  sugar  be  present  in  marked  quantity,  must  be  regarded  as 
almost  a  positive  bar  to  operation.  In  the  condition  of  glycosuria,  wounds 
have  a  tendency  to  remain  open;  they  will  not  heal,  and,  still  more,  they  are 
apt  to  run  into  spreading  gangrene.  This  is  notably  the  case  if  the  lower 
extremity  be  the  seat  of  the  wound  or  operation.  Here  all  attempts  to  arrest 
the  diabetic  gangrene  commonly  prove  futile,  and  the  disease  spreads  obsti- 
nately, slowly,  and  continuously,  until  the  patient  sinks  from  exhaustion. 

Liver. — The  liver  is  so  intimately  associated,  both  physiologically  and 
pathologically,  with  neighboring  organs,  that  it  is  somewhat  difficult  to 
define  the  precise  limits,  in  surgical  cases,  over  which  its  power  is  exercised. 
This  much,  however,  may  be  said,  that  a  diseased  liver  always  increases  the 
risks  of  operation,  and  favors  the  development  of  hemorrhage,  inflammation, 
and  constitutional  septic  poisoning.  And  this  is  so  whether  the  case  be  one 
merely  of  torpid  or  inactive  liver,  or  whether  decided  organic  changes  have 
already  occurred.  If  the  liver  has  undergone  either  fatty  or  amyloid  enlarge- 
ment, its  evil  influences  are  greatly  augmented,  and,  before  operation,  careful 
examination  should  be  instituted  to  ascertain  the  fact.  The  existence  of  a 
fatty  liver  may,  indeed,  be  looked  upon  as  an  evidence  of  further  internal 
mischief.  It  may  be  that  the  patient  is  suffering  under  some  exhausting 
affection,  or  that  he  is,  possibly  secretly,  intemperate.  In  amyloid  or  waxy 
degeneration  of  the  liver,  so  often  associated  with  splenic  enlargement,  renal 
albuminuria,  and  the  syphilitic  or  tubercular  cachexia,  the  prognosis  of 
operations  is  unfavorable  in  the  highest  degree.  In  long-continued  suppura- 
tion of  bones,  amyloid  degeneration  often  occurs  in  the  spleen,  kidney,  and 
liver,  in  the  order  mentioned,  although  either  may  be  selected  as  its  point  of 
primary  development,  and  sometimes  nearly  all  the  organs  in  the  body  are 
similarly  affected.  Cirrhosis  of  the  liver,  whether  the  result  of  alcoholism  or 
other  causes,  exercises  also  a  most  deleterious  effect  on  operative  results.  In 
fact,  whenever  the  liver  is  diseased,  no  matter  from  what  cause,  it  is  a  fair 
inference  that  the  other  organs  adjunct  to  the  portal  circulation  are  more  or 
less  involved;  and  this  must  necessarily  be  so  from  the  intimate  and  abundant 
vascular  connection  which  exists  between  the  liver  and  other  abdominal 
viscera.  The  result  will  be  portal  disturbance,  poor  digestion,  and  imperfect 
assimilation — conditions  which  separately  or  in  the  aggregate  promise  badly 
for  the  success  of  the  operator. 

Bowel  Affections. — The  contra-indications  to  operation  offered  by  the  exist- 
ence of  diarrhoea  and  dysentery' are  so  evident  as  to  require  but  a  passing 
mention.  No  surgeon  would  deliberately  operate  at  such  time,  yet  it  occa- 
sionally happens  that  a  patient,  seemingly  healthy,  may  die  shortly  after 
operation  from  the  development  of  a  fresh  attack  of  obstinate  chronic  dysen- 
tery contracted  years  previously.  This  has  always  been  the  experience  of 
military  practice,  and  has  been  fully  corroborated  in  the  annals  of  our  own 
military  service.  The  writer  has  on  several  occasions  known  officers  and 
soldiers,  who  had  long  since  recovered,  as  they  supposed,  from  the  dreaded 


468  OPERATIVE   SURGERY   IN   GENERAL. 

Mexican  or  malarial  dysentery,  succumb  to  a  fresli  attack  on  the  receipt  of 
some  slight  injury,  or  the  performance  of  some  comparatively  trilling  opera- 
tion. 

Cachexia. — The  influence  of  the  different  cachexia  upon  operations  may 
be  regarded  from  a  twofold  point  of  view.  In  the  first  place,  as  to  the 
chances  of  immediate  recovery  from  operations  and  the  healing  of  wounds, 
and,  secondly,  as  to  the  ultimate  result.  In  regard  to  scrofulous  patients,  it 
is  a  matter  of  daily  observation  that  they  do  well  after  operations.  The 
removal  of  the  source  of  irritation,  the  doing  away  with  their  chronic  dis- 
charges, the  relief  from  pain  which  they  experience,  all*  contribute  to  an 
improvement  in  their  general  health.  If  they  are  carefully  watched  and  well 
nourished,  and  if  their  general  hygiene  and  the  ventilation  of  their  rooms  be 
attended  to,  their  wounds  of  operation  will  heal — possibly  slowly,  sometimes 
not  altogether  perfectly,  but  still  in  some  sort  or  other  they  close.  The  cica- 
trices of  the  scrofulous,  as  one  would  naturally  suppose,  are  poorly  organized, 
and  have  a  tendency  to  open,  if  the  diathesis  continues  to  exert  its  force ;  the 
latter,  too,  may  give  fresh  evidence  of  its  power  in  other  parts.  The  pre- 
vious training  of  suffering  which  scrofulous  patients  have  undergone  stands 
them  at  this  time  in  good  stead.  They  bear  confinement  well  if  it  is  not  too 
prolonged,  and  seem  to  be  exempt  from  the  influence  of  septic  poisons  which 
sweep  away  healthier  persons.  The  influence  of  tuberculosis  has  already  been 
alluded  to  in  the  remarks  upon  pulmonary  disease.  The  general  rule  there 
laid  down,  that  operative  interference  should  be  confined  to  cases  of  quiet 
and  suspended  phthisis,  is  equally  applicable,  with  a  change  of  terms,  to  the 
general  diathesis.  In  short,  operation  should  only  be  attempted  when  with- 
out it  the  patient  must  die,  and  when  the  removal  of  the  source  of  irritation 
is  attended  with  less  immediate  danger  to  life  than  its  retention. 

Constitutional  syphilis  undoubtedly  in  many  cases  influences  unfavorably 
operative  results,  but,  at  the  same  time,  it  need  not  be  considered  as  absolutely 
forbidding  operation.  There  is  probably  in  such  cases  a  tendency  greater  or 
less  to  secondary  hemorrhage,  in  consequence  of  the  predisposition  to  disease 
of  the  walls  of  the  larger  arteries  ;  and  this  must  be  borne  in  mind  in  apply- 
ing the  ligatures.  The  wounds  made  in  syphilitic  subjects  do  not  always 
heal  kindly ;  primary  union  is  sometimes  difficult,  or,  if  partially  effected, 
the  adhesions  may  break  up  suddenly  and  apparently  without  sufficient 
cause.  Hence  it  happens  that  plastic  operations,  particularly  on  parts  in  the 
vicinity  of  the  genital  region  which  have  been  the  seat  of  previous  destructive 
processes,  are  often  unsuccessful,  and  that  attempts  to  close  fistula?  and  losses 
of  substance  are  commonly  of  no  avail. 

Operations  upon  cancerous  patients  are  constantly  performed  where  neces- 
sity commands,  and  there  is  no  reason  why  they  should  not  be  done.  These 
wounds  heal  readily,  and  there  is  no  evidence  to  show  that  the  constitutional 
condition  of  the  patient  is  rendered  more  unfavorable.  The  question  in  such 
cases  is  simply  one  of  expediency,  and  the  surgeon  must  decide  from  a  careful 
consideration  of  the  circumstances  surrounding  each  individual  at  the  time. 

The  gouty  and  rheumatic  diatheses  are  supposed  to  act  in  a  measure  as 
contra-indicating  operations.  As  far  as  they  impair  the  strength  of  the 
patient,  this  is  so;  and  no  one  would  willingly  select  the  period  of  an  attack 
of  gout,  or  of  the  acute  febrile  stage  of  rheumatism,  as  the  time  of  operation. 
As  is  well  known,  in  gouty  persons,  any  constitutional  disturbance  may  give 
rise  to  a  fresh  attack.  In  rheumatic  patients,  the  tendency  to  cardiac  com- 
plications, and  the  possible  exacerbations  of  existing  disease  by  operative 
interference,  must  always  be  borne  in  mind.  The  lithic acid  diathesis  is  like- 
wise unfavorable  to  operation,  since  it  is  usually  accompanied  by  impaired 


CONDITIONS    DETERMINING    THE    RESULTS    OF    OPERATIONS.  469 

bodily  strength  and  by  deranged  action  of  the  kidneys.  Operations  during 
an  attack  of  erysipelas,  or  through  tissues  already  affected  by  that  disease, 
must  not  be  practised  if  they  can  possibly  be  avoided.  They  may  only  be 
attempted  in  extreme  cases,  and  where  no  other  means  of  saving  life  are  avail- 
able. Under  such  circumstances,  the  most  active  stimulant  and  tonic  treat- 
ment, and  the  free  exhibition  of  iron  preparations,  should  be  carefully  pressed. 
Cutaneous  eruptions  not  unfrecpiently  occur  as  the  sequence  of  operation. 
Allusion  has  already  been  made  to  the  scarlatina  of  children.  Urticaria  is 
often  consequent  upon  operations  on  the  genital  organs,  and  erythema,  some- 
times of  a  very  intense  type,  is  not  unusual.  Erysipelas  need  only  be  men- 
tioned in  this  connection,  forming,  as  it  does,  in  conjunction  with  disintegra- 
tion and  gangrene  of  the  cellular  tissue,  one  of  the  common  causes  of  death 
after  operation.  Purpura  and  ecchymotic  extravasations  are  evidences  of 
blood-poisoning,  and  are  not  rare  in  depraved  constitutions. 

Conditions  Connected  with  the  Operation  Itself. — There  are  certain  con- 
ditions, incident  to  the  performance  of  operations,  accidents  as  it  were,  which 
greatly  influence  the  result.  One  of  the  most  potent  of  these  is  pain,  which 
in  itself  is  depressing  and  conducive  to  shock,  especially  in  children,  who  so 
illy  sustain  it.  Fortunately,  the  discovery  of  anaesthesia,  perhaps  the  greatest 
blessing  which  has  been  conferred  on  suffering  humanity,  has  deprived  surgery 
of  half  its  terrors,  and  the  operator  is  seldom  justified  in  attempting  "any 
serious  operative  procedure  without  resorting  to  it. 

Hemorrhage,  once  the  dread  of  the  surgeon,  has  too  in  great  part  been  over- 
come, and  the  importance  of  Esmarch's  invaluable  contribution  of  bloodless 
surgery  cannot  be  overestimated.  It  is  a  mistake  to  suppose  that  bleeding  is 
advantageous  in  operations,  for  it  must  be  remembered  that  the  blood  is  a  fluid 
of  complex  formation,  and  that,  once  withdrawn  from  the  body,  its  place  can- 
not be  readily  supplied.  The  baneful  effect  of  bleeding  on  children  and  in 
the  old  is  very  decided,  and  has  much  to  do  with  the  production  of  shock. 
The  relative  loss  of  blood  is  often  the  turning  point,  as  to  recovery  or  death 
after  an  operation.  It  is  dangerous  when  it  occurs  as  a  primary  accident,  and 
even  more  so  in  its  secondary  forms.  In  the  first  case,  it  contributes  directly 
to  shock,  and  in  the  latter,  indirectly  to  the  predisposition  to  septic  poisoning. 
It  must  therefore  be  carefully  guarded  against,  as  well  at  the  time  of  opera- 
tion as  in  the  after  conduct  of  the  case.  If  it  is  evident  during  an  operation 
that  too  much  blood  is  being  lost,  and  symptoms  of  exhaustion  become  appa- 
rent, the  head  of  the  patient  must  at  once  be  lowered,  to  favor  the  access  of 
blood  to  the  brain.  The  respiratory  efforts  must  be  stimulated  by  the  vapor 
of  ammonia  and  cold  aspersions,  and,  if  the  temperature  of  the  body  continue 
to  fall,  artificial  heat  must  be  applied.  Excessive  hemorrhage  during  opera- 
tion is  much  to  be  dreaded  when  it  occurs  in  patients  who  are  already  anaemic 
from  any  cause.  In  military  practice  secondary  bleeding  has  oftei/been  too 
common,  particularly  in  men  who  have  been  ovcrmarchcd,  and  whose  vital 
powers  have  been  broken  down  hy  privation,  nervous  exhaustion,  defective 
diet,  and  exposure  to  malarial  and  other  depressing  climatic  causes.  Under 
these  circumstances,  prolonged  transportation  in  wagons  and  rude  ambu- 
lances has  proved  most  injurious  by  inducing  bleeding;  and  the  writer  has 
known  many  a  life  thus  lost,  which  might  have  been  saved  if  the  exigencies  of 
war  had  only  permitted  the  sufferer  to  rest  in  quiet  near  the  scene  of  conflict. 

Shock, — A  powerful  element  in  the  production  of  shock  is  prolonged  opera- 
tion. In  some  instances,  this  would  seem  to  be  chargeable  to  the  very  state 
of  anaesthesia.  When  a  patient  is  insensible  to  pain,  the  surgeon  may  be 
tempted,  perhaps  unconsciously,  to  extend  his  operation  over  a  longer  period 
than  is  altogether  judicious.     Then  too  there  is  sometimes  undue  exposure  of 


470  OPERATIVE   SURGERY   IN   GENERAL. 

the  patient  to  draughts  of  air,  and  he  becomes  unnecessarily  chilled  ;  and  full 
reaction,  upon  which  so  much  depends,  takes  place  slowly.  The  development 
of  the  shock  of  operation  is  thus  favored.  It  may,  however,  result  from  the 
previous  effects  of  mental  depression.  In  one  or  two  instances  the  writer  has 
seen  it  brought  about,  or  at  all  events  greatly  augmented,  by  fear;  in  fact, 
in  one  well-remembered  case,  from  fear,  carried  to  such  a  state  of  abject  cow- 
ardice and  demoralization  as  to  lead  to  disastrous  consequences  on  the  recep- 
tion of  an  insignificant  wound.  Surgical  shock  often  accompanies  large  ope- 
rations, or  operations  on  internal  viscera,  and,  as  a  rule,  the  more  extensive  the 
operation  or  mutilation,  the  more  intense  will  be  the  resulting  shock.  It  may, 
however,  attend  comparatively  trifling  wounds  or  injuries,  and  the  writer  has 
seen  it  present  in  an  exaggerated  form,  in  one  instance,  where  the  spermatic 
cord  was  merely  grazed  by  a  bullet.  The  time  of  operation  has  much  to  do 
with  the  result.  Thus,  as  a  rule,  no  operation  ought  to  be  attempted  during 
the  existence  of  shock,  but  the  surgeon  should  watchfully  await  the  period  of 
reaction.  Exceptions  to  this  law,  it  is  true,  may  arise  from  the  absolute  ne- 
cessities of  the  moment ;  for  example,  a  limb  may  be  almost  torn  off  by  a 
shot,  or  piece  of  shell,  or  may  be  hopelessly  crushed  in  a  railroad  accident, 
and  its  prompt  removal  may  be  demanded  by  uncontrollable  hemorrhage,  or 
reaction  after  injury  may  be  tardy,  and  the  state  of  shock  be  kept  up  by  the 
presence  of  the  mutilated  member.  Here  immediate  operation  may  be  proper, 
and  indeed  necessary  to  release  the  patient  from  his  depressed  condition,  and 
thus  preserve  life.  The  relative  influence  of  primary  and  secondary  operations 
must  also  be  considered,  particularly  in  military  practice,  and  when  coupled 
with  the  question  of  after  transportation.  Intermediate  operations,  or  those 
practised  during  the  existence  of  traumatic  fever,  and  before  the  arrival  of  the 
true  secondary  fever,  should  be  discountenanced;  since  errors  of  judgment  in 
this  respect  have  too  often  led  to  unfortunate  results. 

Local  Condition. — The  local  condition  of  a  part  must  always  be  carefully 
considered ;  and  operations  should  not  be  performed  through  unhealthy  tis- 
sues, or  through  those  which  are  inflamed,  sloughing,  or  gangrenous,  or  in 
which  phlebitis  exists.  Neither  should  plastic  operations  be  repeated  too 
soon  after  previous  failures  in  obtaining  union,  but  sufficient  time  should  be 
granted  to  the  tissues  involved  to  harden  and  return  to  their  original  state. 
Neglect  of  this  precaution  is  almost  sure  to  be  followed  by  the  cutting  out  of 
pins  and  sutures,  and  by  failure  to  unite. 

Hemorrhagic  Diathesis. — There  is  one  state  of  the  system  which  greatly 
affects  the  question  of  operation;  it  is  the  existence  of  haemophilia  or  the 
hemorrliityii'  diathesis.  Fortunately  this  is  not  common, but  still  many  cases  have 
been  recorded  in  which  death  has  resulted,  often  after  trifling  operations,  and 
for  which  the  surgeon  1ms  been  severely,  and  generally  unjustly,  blamed.  It 
behooves  him,  therefore,  to  be  on  his  guard,  and  always  to  make  inquiry  before 
operating,  whether  the  peculiarity  has  ever  been  observed  in  the  patient  or 
his  relatives,  for  the  disease  not  unfrequently  affects  several  members  of  a 
family,  who  are  often  spoken  of  as  "bleeders."  If  the  answer  is  an  affirma- 
tive one,  the  utmost  caution  should  be  observed;  or,  better  still,  if  the  patient 
himself  possesses  this  constitutional  proclivity,  no  operation  should  be  per- 
formed,  unless  life  be  at  stake. 

Condition  of  Patient  after  Operation. — The  hygienic  surroundings  of 
the  patient  after  operation,  are  of  vital  importance.  If  he  is  to  be  treated  in 
a  private  house,  it  becomes  the  duty  of  the  surgeon  to  see  to  these  matters 
himself,  and  not  to  trust  to  the  well  meant  but  often  badly  executed  inten- 


CONDITIONS    DETERMINING    THE    RESULTS    OF    OPERATIONS.  471 

tions  of  the  family  or  friends  of  the  patient.  Every  precaution  must  be  taken 
to  insure  cleanliness  in  the  widest  sense  of  the  term;  a  proper  bed  and  bed- 
ding ought  to  be  provided,  and  rubber  cloths  to  prevent  soiling  by  the  dis- 
charges ;  all  unnecessary  hangings  and  draperies  should  be  taken  down  as 
possible  receptacles  of  dust,  and  of  orgaDic  poisonous  matters  and  emanations. 
The  bed  should  be  so  placed  as  to  be  out  of  the  way  of  draughts  of  air  from 
doors  and  windows,  and  of  direct  currents  of  heat  from  hot-air  flues,  while  at 
the  same  time  convenient  arrangements  must  be  adopted  to  insure  satisfactory 
ventilation,  the  temperature  of  the  room  being  regulated  by  a  thermometer. 
All  excreta  ought  to  be  removed  at  once,  and  every  means  adopted  to  keep 
the  room  tidy,  and  the  patient  in  as  clean  and  comfortable  a  condition  as  pos- 
sible. Disinfectants  should  be  freely  used,  not  only  in  the  room,  but  about 
the  patient,  whose  person,  where  no  objection  exists,  should  everyday  be  care- 
fully sponged  and  dried  without  uncovering  him  unduly. 

The  hygiene  of  hospitals  has  of  late  years  been  made  the  subject  of  elabo- 
rate study,  and  is  daily  attracting  more  attention.  In  all  well-ordered  hos- 
pitals, the  diet  sheets  are  usually  sufficient  and  well  arranged,  and  the  personal 
cares  rendered  by  the  attendants  are  properly  watched.  The  great  danger  in 
all  large  hospitals  is,  however,  that  of  overcrowding;  of  bringing  too  many 
patients  under  one  roof.  Xot  only  ought  this  to  be  guarded  against,  but  care 
should  be  exercised  to  see  that  the  wards  are  not  too  large ;  from  twenty-five 
to  thirty  beds  is  a  quite  sufficient  capacity  for  any  one  ward.  The  amount  of 
air  space  usually  regarded  as  sufficient  for  surgical  cases,  is  from  fifteen 
hundred  to  two  thousand  cubic  feet,  with  a  floor  area  of  from  one  hundred  to 
one  hundred  and  thirty  or  forty  square  feet  for  each  patient.  These  figures 
are  all  very  well  as  far  as  they  go,  but  it  is  well  to  see  that,  even  with  full 
averages,  the  height  of  the  ceiling  is  sufficient,  not  less  than  fifteen  or  six- 
teen feet.  Different  systems  have  been  devised  for  bringing  in  fresh  air,  and 
getting  rid  of  the  foul  air,  by  means  of  upward  and  downward  currents,  and 
by  the  use  of  steam  fans.  Such  ingenious  methods  have  doubtless  gone  far 
to  purify  hospital  wards  ;  at  the  same  time  there  is  reason  to  believe  that  the 
best  system  of  obtaining  ventilation  and  insuring  perfect  change  of  air  is  that 
which  may  be  called  the  natural  one,  namely,  by  doors,  windows,  and  open 
fireplaces.  Ventilation  and  change  of  air  during  the  night  are  strongly  to 
be  insisted  upon,  and  the  persistent  efforts  of  hospital  attendants  to  close  up 
their  wards  tightly  during  the  hours  of  sleep,  ought  to  be  watchfully  anticipated 
and  restrained.  The  population  of  large  wards  ought  also  to  be  vigilantly 
scrutinized,  and  too  many  suppurating  cases  should  not  be  placed  in  one  room. 
Patients  with  bad  sloughing  sores  and  putrid  emanations  had  best  be  isolated 
when  practicable,  in  order  to  prevent  ward  contamination,  and  every  ward 
should  from  time  to  time  be  emptied  and  thoroughly  cleansed  and  disinfected. 
In  other  words,  no  effort  should  be  spared  to  preserve  the  purity  of  a  ward, 
and  to  permit  at  all  times  the  free  access  of  fresh  air,  in  itself  the  most 
thorough  of  all  disinfectants.  The  importance  of  good  hospital  drainage 
must  never  be  forgotten,  and,  in  effecting  this,  proper  measures  ought  to  be 
taken  to  prevent  the_  backing  of  sewer  gas,  which  not  unfrequently  occurs 
from  defective  trapping.  Such  emanations  are  of  the  most  deadly  character, 
and  are  fearfully  potent  in  giving  rise  to  various  forms  of  blood-poisoning. 
Mr.  Eriehsen,  in  his  truthful  and  forcible  remarks  on  the  overcrowding  of 
hospitals,  has  pertinently  pointed  out  the  baneful  influences  of  deficient  sani- 
tary regulations,  and  has  shown  how  cruel  such  a  system  is  to  patients,  and 
how  unjust  to  hospital  surgeons  ;  inflicting  on  the  former  an  unnecessarily  high 
rate  of  mortality,  and  on  the  latter  an  undue  burden  of  anxiety  and  respon- 
sibility. 

The  subject  of  civil  and  military  hospital  construction  and  organization  is. 


472  OPERATIVE    SURGERY    IN   GENERAL. 

foreign  to  the  present  article.  Yet  it  may  be  said  that  for  military  purposes 
the  well-known  pavilion  system  of  hospitals,  with  a  central  building  for  fid- 
ministration,  is  probably  the  most  perfect  which  can  be  designed.  It  has 
also  been  shown  practically  that  the  same  system,  with  certain  modifications, 
can  be  made  applicable  to  the  erection  of  civil  hospitals  when  sufficient  ground 
can  be  obtained.  One  advantage  of  this  system  is  the  possibility  of  its  ex- 
pansion to  almost  any  extent,  an  important  consideration  in  the  foundation 
of  hospital  charities  designed  to  meet  the  wants  of  rapidly-growing  popula- 
tions. The  experience  of  our  late  war  conclusively  proved  the  advantages 
of  the  pavilion  system  of  hospital  construction,  and  the  history  of  the  mag- 
nificent and  extensive  pavilion  hospitals,  which  then  sprang  up  over  our  whole 
country,  will  remain  forever  as  a  memorial  of  the  intelligence,  zeal,  and  ready 
adaptability  to  circumstances,  which  characterized  the  services  of  our  army 
medical  staff'.  Perhaps  in  this  connection  it  may  not  be  amiss  to  refer  to  the 
excellent  results  which  at  that  time  attended  operations  treated  in  tent  hos- 
pitals. As  is  well  known,  after  severe  battles,  vast  numbers  of  wounded  were 
thrown  upon  the  hands  of  the  army  surgeons.  These  patients  were  accommo- 
dated in  division,  corps,  and  general  hospitals  placed  near  the  seat  of  action. 
These  hospitals  were  composed  of  hospital  tents,  the  number  used  being 
suited  to  the  urgency  of  the  occasion,  and  varying  from  ten  or  a  dozen  up  to 
several  hundred.  Four  or  live  or  more  of  these  tents  were  often  pitched  end 
to  end,  arranged  in  conformity  with  the  lay  of  the  ground,  so  as  to  form 
wards  of  proper  size,  which  could  be  readily  cared  for  and  overlooked  by  the 
nurses  and  medical  attendants.  In  winter  weather  and  during  the  heat  of 
summer,  these  tents  were  protected  by  the  army  tent-fly.  In  cold  weather,  the 
warming  was  accomplished  by  small  iron  wood-stoves.  In  many  instances, 
where  it  was  probable  that  the  hospital  would  be  in  use  for  some  time,  board 
floors  were  laid  down.  Whether  this  was  realty  an  advantage  or  otherwise 
seemed  at  times  questionable.  Tents  so  furnished  looked  better,  it  is  true, 
but  were  open  to  the  objection  of  foul  accumulations  taking  place  beneath 
the  floor.  They  were  supposed  to  be  more  free  from  dampness,  but  this  could 
usually  be  guarded  against  by  proper  trenching,  and  it  is  not  impossible  that 
the  earth  floor  in  itself  was  preferable  from  its  inherent  antiseptic  qualities. 
During  this  period  it  was  surprising  to  note  how  well  operations  did,  and  how 
rapidly  convalescence  took  place  under  these  simple  arrangements,  which, 
rough  as  they  might  seem  to  the  unprofessional  eye,  were  undoubtedly  to  be 
preferred  to  any  form  of  barrack,  or,  indeed,  permanent  hospital. 


Causes  of  Death  after  Operations. 

Hemorrhage. — Death  may  occur  during  or  after  an  operation  from  different 
causes,  acting  singly  or  in  combination.  It  may  result,  in  the  first  place, 
from  hemorrhage;  and  the  more  rapidly  this  takes  place,  and  the  greater  its 
amount,  the  more  depressing  and  disastrous  will  be  its  effects.  If  it  be  very 
excessive,  death  may  be  almost  immediate;  but  generally  in  operations, 
although  bleeding  may  possibly  be  profuse,  it  is  prolonged,  marked  by 
quantity  rather  than  by  rapidity,  and  by  timely  and  vigorous  effort  it  may 
be  arrested.  There  are  instances,  too,  where,  although  not  great  in  extent, 
its  effects  may  at  the  time  be  pronounced,  and,  in  the  end,  fatal.  This  is 
apt  to  be  the  case  in  patients  of  broken-down  constitution,  and  wdio  are 
usually  spoken  of  as  bad  subjects  for  operation.  These  fail  to  react,  and 
either  sink  from  exhaustion  or  fall  ready  victims  to  septic  or  intercurrent 
discuses.  Fortunately,  at  the  present  day, -death  upon  the  operating  table 
from  bleeding  rarely  happens,  since  the  resources  of  modern  surgery  have 


CAUSES  OF  DEATH  AFTER  OPERATIONS.  473 

placed  in  the  hands  of  the  operator  so  many  and  such  ingenious  means  of 
preventing  such  an  occurrence ;  at  the  same  time,  it  is  just  possible  that  the 
very  employment  of  some  of  these  means  of  controlling  the  primary  flow 
may  predispose  to  its  secondary  occurrence.  Thus,  if  Esmarch's  upper 
bandage  be  drawn  too  tightly,  it  may  by  its  pressure  prevent  bleeding  from 
vessels  of  medium  size,  which  it  were  well  to  ligate,  so  that  on  the  removal 
of  the  constriction  and  on  full  reaction,  after  the  patient  has  been  carried  to 
his  bed,  troublesome  bleeding  may  set  in.  This  fact  must  be  remembered, 
and  caution  should  be  observed  in  regulating  the  pressure  at  the  time  of 
operation;  and  very  careful  search  must  be  instituted  for  bleeding  points. 
Secondary  arterial  hemorrhage  may  happen  at  any  moment,  from  the  hour 
of  operation  until  the  deep  portions  of  the  wound  are  healed.  It  may  result 
from  imperfect  ligation,  from  enlargement  of  the  vessels,  from  too  rapid  and 
great  development  of  the  collateral  circulation,  from  sloughing,  from  atheroma 
of  the  arteries,  or  from  premature  falling  of  the  ligatures.  Secondary  venous 
bleeding  may  take  place  from  the  backward  flow  of  blood  at  points  destitute 
of  valves,  either  where  the  valves  are  normally  deficient,  or  where  they  have 
become  imperfect  from  disease ;  or  bleeding  may  occur  from  veins  where  a 
varicose  condition  exists.  And  in  this  connection  it  may  be  said  that  there 
is  no  reason  why  the  veins  which  bleed  should  not  be  tied  in  amputations. 
The  risk  of  so  doing  is  exaggerated ;  the  writer  has  frequently  practised  such 
ligations,  and  has  known  many  instances  where  others  have  pursued  the  same 
course  with  good  results.  Venous  bleeding  may  also  be  caused  after  ampu- 
tation by  adhesive  strips  or  bandages  applied  circularly  around  the  stump, 
so  as  to  produce  too  much  pressure  when  swelling  of  the  part  has  occurred. 
The  danger  of  bleeding,  let  the  cause  be  what  it  may,  cannot  be  overesti- 
mated, constituting,  as  it  so  often  does,  the  turning  point  in  the  case,  and 
forming  one  of  the  factors  in  the  production  and  maintenance  of  shock. 

Shock. — The  shock  of  operation,  familiar  to  every  surgeon,  is  usually  the 
result  of  no  single  cause,  but  rather  of  several  combined.  Hemorrhage, 
anaesthesia,  prolonged  manipulation,  chilling  of  the  body  consequent  upon 
exposure  to  the  air,  and  the  operative  lesion  to  the  tissues,  are  alike  con- 
cerned in  bringing  about  the  prostration  which  characterizes  this  state. 
Mental  causes  also  exert  no  slight  predisposing  influence  in  the  production 
of  shock.  There  is  scarcely  any  better  preparation  for  a  patient  about  to 
submit  to  operation  than  a  bright,  hopeful  disposition  ;  there  is  none  worse 
than  despondency  and  dread.  Other  things  being  equal,  the  chances  of 
recovery  in  the  former  instance  are  far  better  than  in  the  latter.  Shock  is 
usually  attended  by  extreme  depression  of  the  nervous  system  and  inter- 
ference with  the  action  of  the  heart.  The  skin  is  of  a  waxy-white  pallor ; 
there  is  loss  of  color  in  the  face,  and  particularly  in  the  lips ;  a  cold  clammy 
perspiration,  with  sweat-drops  forming  on  the  forehead ;  and  a  pinched  and 
contracted  expression  of  countenance.  There  is  intense  muscular  prostra- 
tion, loss  of  bodily  temperature,  feeble  respiration,  and,  in  extreme  cases, 
relaxation  of  the  sphincter  muscles.  The  pulse  becomes  feeble  and  irregular, 
and  sometimes  cannot  be  detected  at  the  wrist.  If  an  anaesthetic  has"  been 
used,  it  will  be  difficult  to  form  an  opinion  of  the  condition  of  the  special 
senses ;  but,  if  not,  these  will  be  found  to  be  somewhat  dulled  and  interfered 
with.  Intellection  may  remain  in  part — ordinarily,  however,  accompanied 
by  some  degree  of  hebetude  or  bewilderment.  In  milder  cases  of  shock, 
there  are  not  unfrequently  nausea  and  vomiting,  the  latter  of  which  is  usually 
followed  by  reaction.  Where  the  shock  is  very  great  and  prolonged,  death 
occurs  from  cessation  of  the  heart's  action;  and  this  may  at  times  happen 


474  OPERATIVE    SURGERY    IN   GENERAL. 

as  a  purely  nervous  effect,  independent  of  hemorrhage  or  the  other  lethal 
causes  referred  to. 

Another  cause  of  shock,  of  more  common  occurrence  than  it  should  be,  is 
too  prolonged  or  lengthy  operation ;  and  this  must  be  carefully  guarded 
against,  particularly  in  childhood  and  old  age — periods  of  life  more  than  all 
others  susceptible  to  depressing  influences.  Pain,  if  great  or  of  long  dura- 
tion, either  at  the  time  of  operation  or  afterwards,  contributes  not  a  little  to 
prostration,  and  may  weigh  down  the  scale  of  life  and  death.  Violence  dur- 
ing operation,  or  roughness  of  manipulation,  leading  to  bruising  of  delicate 
tissues,  as  the  prostate  gland  and  neck  of  the  bladder,  may  produce  disastrous 
consequences,  and  the  more  so  if  such  efforts  are  persisted  in  for  any  length 
of  time ;  and  the  same  may  be  said  of  forcible  extension  of  the  knee-joint,  a 
procedure  too  often  fraught  with  fatal  shock. 

When,  from  any  circumstance,  a  condition  of  sudden  depression,  prostration, 
or  shock,  is  becoming  apparent  during  or  immediately  following  operation, 
the  most  active  measures  must  be  instantly  resorted  to.  Hemorrhage  must 
be  stopped  at  once,  even  if  the  operation  has  to  be  temporarily  discontinued ; 
the  patient's  body  must  be  elevated,  and  his  head  made  dependent,  so  as  to 
invite  the  flow  of  blood  to  the  brain.  With  the  same  intent,  the  large  arteries 
of  the  extremities  may  be  compressed  by  tourniquets,  so  as  for  the  time  to 
cut  off'  the  vascular  supply  in  this  direction,  and  increase  the  amount  avail- 
able for  the  demands  of  the  central  organs.  The  anesthetic  should  be  imme- 
diately withdrawn,  and  the  vapor  of  ammonia  and  that  of  nitrite  of  amyl 
employed  for  their  stimulating  effects.  The  temperature  of  the  body  should 
be  kept  up  by  the  application  of  hot-water  bottles  and  cloths  to  the  trunk 
and  limbs,  and  by  the  use  of  stimulating  or  hot-water  enemata.  If  the  loss 
of  blood  has  been  very  severe,  transfusion  should  be  attempted.  The  success 
of  this  measure  in  chronic  hemorrhages  has  been  sufficiently  great  to  warrant, 
and,  indeed,  command,  its  employment  as  an  immediate  resource  in  acute 
suro-ical  cases,  where  of  all  others  its  happy  influence  may  be  expected.  Any 
of  the  different  processes  may  be  resorted  to,  but  caution  should  be  observed 
as  to  the  quantity  of  blood  injected ;  not  more  than  three  or  four  ounces 
should  be  thrown  in  at  first,  and  the  effects  of  the  operation  carefully 
watched.  Usually,  if  this  has  not  been  too  long  delayed,  these  are  promptly 
marked  by  the  stronger  heart-beats  and  the  improved  character  of  the  pulse. 
If  blood  cannot  be  readily  obtained,  intra-venous  injections  of  milk  or  other 
fluids  can  be  made,  in  the  manner  described  in  another  part  of  this  work. 
(See  Article  on  Minor  Surgery.)  Hypodermic  injections  of  ether  may  also 
be  used  as  a  substitute  for  transfusion,  with  excellent  results. 

Occasionally  it  happens  that  death  after  operation  results  from  secondary 
shock  or  exhaustion.  This  is  most  frequently  the  case  in  old  persons,  or  those 
of  delicate  constitution,  or  of  impressionable  temperament.  In  them  the  first 
reaction  is  apparently  complete  and  satisfactory  ;  the  respiration  and  circula- 
tion seem  good  ;  they  sleep  ;  and  there  may  be  sonic  return  of  appetite.  These 
favorable  appearances  arc,  however,  delusive  and  of  short  duration,  for  in  a 
little  while,  it  may  be  at  the  expiration  of  eight  or  ten  hours,  or  perhaps  even 
after  two  or  three  days,  the  patient  becomes  weaker  and  weaker,  and  slowly 
relapses  into  a  condition  of  shock,  from  which  he  cannot  be  extricated,  and 
which  continues  until  death.  Sometimes  the  patient's  downward  course  is 
rapid,  at  other  times  very  gradual.  Usually,  in  these  cases,  the  mind  remains 
clear  to  the  last,  and  the  patient  seems  indifferent  as  to  his  condition.  It  is 
difficult  to  offer  any  explanation  of  the  state  of  secondary  shock,  except  on 
the  idea  of  exhaustion  of  the  heart,  and  the  giving  out  of  its  power,  dependent 
upon  some  of  the  causes  already  spoken  of.     Heart  clot,  formed  during  the 


CAUSES  OF  DEATH  AFTER  OPERATIONS.  475 

operation,  is  the  pathological  condition  found  in  many  of  these  cases,  and  its 
ill  effects  may  be  sometimes  obviated  by  the  free  administration  of  ammonia, 
either  by  the  month  or  by  intravenous  injection. 

Delirium. — Death  may  also  take  place  after  operation,  or  after  injury,  by 
the  setting  in  of  delirium.,  which  usually  presents  itself  as  an  acute  affection 
in  one  of  three  forms.  In  the  first  place,  it  may  appear  as  acute  traumatic  de- 
lirium, attended  by  symptoms  of  a  highly  inflammatory  character.  The  pulse 
is  then  quick  and  full,  the  face  flushed,  the  skin  hot  and  dry,  the  eyes  suffused, 
the  restlessness  and  jactitation  extreme,  and  the  mental  condition  varying 
from  incoherent  babble  and  disjointed  talk  up  to  the  most  violent  busy  excite- 
ment. In  another  class  of  cases,  and  by  far  the  most  common,  the  affection 
is  a  true  delirium  tremens,  characterized  by  all  its  well-known  symptoms,  tre- 
mors, delusions,  and  fancies.  This  form  of  delirium  occurs  in  persons  of  in- 
temperate habits,  and  in  those  who  have  been  recently  drinking.  It  is  also 
met  with  in  such  as  have  been  only  moderate  drinkers,  and  in  those  who  have 
discontinued  their  habits  in  this  respect  for  some  time.  The  occurrence,  after 
operation,  of  either  of  these  forms  of  delirium  is  a  most  serious  complica- 
tion, and  although  many  patients  do  recover  from  them,  the  prognosis  is 
always  grave,  and  not  a  few  perish.  One  peculiarity  of  patients  suffering 
from  these  invasions  of  delirium  is  their  indifference  to  pain,  and  their  con- 
stant tendency,  and  often  persevering  attempts,  to  do  themselves  bodily  injury, 
by  tearing  off  dressings,  leaping  from  the  bed,  and  inflicting  violence  upon 
themselves  of  every  form.  The  treatment  in  such  cases  readily  suggests  itself. 
In  the  first  place,  such  restraint  must  be  enforced  as  is  necessary,  with  constant 
watching ;  and  for  the  acute  inflammatory  delirium,  cold  to  the  head,  local 
depletion,  and  the  cautious  use  of  sedative  narcotics.  In  the  traumatic  form 
of  delirium  tremens,  the  ordinary  remedies  for  the  treatment  of  this  affection 
must  be  resorted  to,  such  as  bromide  of  potassium,  capsicum,  chloral,  and 
opium,  employed  singly  or  in  combination  as  may  appear  most  appropriate. 
In  many  cases  the  hypodermic  mode  of  medication  will  be  the  only  one 
possible.  The  great  indication  is  to  procure  sleep,  and  the  therapeutic  efforts 
in  this  direction  must  be  steadily  carried  out  until  the  result  is  obtained. 

There  is  one  other  form  of  delirium  after  operation  which  is  occasionally 
encountered. .  This  is  the  traumatic  nervous  delirium  observed  in  females  of  hys- 
terical tendencies,  and  in  persons  of  both  sexes  of  broken-down  constitutions, 
or  in  anremic  conditions.  It  is  sudden  of  invasion,  and  is  attended  with  men- 
tal hallucinations  of  almost  every  sort ;  usually  of  a  quiet  kind,  but  sometimes 
also  of  a  noisy  nature.  This. affection  is  one  of  weakness  rather  than  of  a  true 
inflammatory  nature ;  the  pulse  although  frequent  is  feeble;  the  skin  is  not 
hot,  but  is  often  covered  with  a  cold  perspiration,  and  at  times  tremors  are 
present.  The  prognosis  in  such  cases  is  unfavorable,  and  death  results  in  the 
majority  of  cases.  The  treatment  consists  in  the  employment  of  stimulant 
and  soothing  narcotics. 

Thrombosis  and  Embolism. — Patients  occasionally  perish  after  operation 
from  the  formation  of  a  heart  clot,  or  from  embolism ;  sometimes  the  coagula 
form  in  the  large  vessels,  and  then  by  their  detachment  give  rise  in  turn  to 
heart  clot  and  secondary  embolic  plugging.  There  is  alwa3's  a  predisposition 
to  undue  coagulation  of  the  blood,  after  excessive  bleeding,  and  this  is  greatly 
favored  by  the  occurrence  of  fainting.  The  patient  at  these  times  must  there- 
fore be  kept  quiet,  and  cautiously  moved,  nor  should  he  be  allowed  to  sit  up 
in  bed,  or  to  attempt  any  muscular  exertion  for  fear  of  the  development  of 
fatal  syncope. 


476  OPERATIVE    SURGERY    IN    GENERAL. 

Air  in  Veins. — Another  accident  from  which  death  has  heen  recorded  is 
the  entrance  of  air  into  a  vein,  following  upon  its  incision  during  an  opera- 
tion. This  circumstance  ought  to  he  borne  in  mind  when  large  veins  are 
involved,  particularly  in  the  deep  portions  of  the  neck,  and  when  the  tissues 
are  infiltrated  and  indurated  by  disease.  If  a  vein  of  any  size  be  opened  un- 
der these  conditions,  the  lips  of  the  wound  may,  on  account  of  the  tissue-con- 
nections of  the  vein,  gape  sufficiently  to  permit  the  entrance  of  air,  and  death 
may  ensue,  sometimes  almost  instantly.  Whether  the  presence  of  air  in  the 
right  heart  paralyzes  cardiac  movement,  or  whether  the  air  entering  the 
branches  of  the  pulmonary  artery  causes  cessation  of  the  circulation,  is  a  mat- 
ter for  discussion  ;  yet  the  great  clinical  fact  remains,  and  enforces  upon  the 
surgeon  the  greatest  caution  in  operating  in  these  dangerous  regions. 

Gangrene  and  Sloughing. — Death  after  operations  may  occur,  particularly 
in  military  practice,  from  the  formation  of  sloughing  sores,  or  the  develop- 
ment of  true  hospital  gangrene.  The  latter,  in  this  country,  has,  however, 
been  more  rare  than  it  is  generally  believed  to  have  been ;  many  of  the  cases 
described  as  such  being  in  reality  sloughing  sores,  not  possessing  the  property 
of  contagiousness.  This  was  shown  in  a  remarkable  manner  in  our  late  war, 
where  not  a  few  eases  of  gangrene  from  the  Libby  and  Andersonville  prisons 
reached  the  northern  lines.  These  possessed  apparently  all  the  destructive 
tendencies  and  evidences  of  hospital  gangrene,  but  }-et  when  placed  in  beds 
in  general  hospitals,  under  favorable  hygienic  conditions,  the  disease  evinced 
little  tendency  to  spread  from  bed  to  bed,  or  at  all  events  to  attack  men  who 
had  not  been  exposed  to  the  same  predisposing  causes,  imprisonment,  starva- 
tion, and  exposure.  The  most  effectual  treatment  for  such  cases  consisted  in 
ventilation,  diet,  and  active  cauterization  of  the  sloughing  surfaces  with  pure 
bromine,  as  suggested  by  Dr.  M.  Goldsmith,  late  Surgeon  IT.  S.  Volunteers. 

Tetanus  is  another  cause  of  death  after  operations.  It  may  occur  after 
slight  operations  as  well  as  after  those  of  great  magnitude.  Yet,  in  propor- 
tion to  the  whole  number  of  cases,  it  is,  at  least  in  our  climate,  so  infrequent 
that  it  may  practically  be  disregarded  in  deciding  upon  the  propriety  of  ope- 
ration. Almost  every  imaginable  circumstance  has  been  advanced  as  an  ex- 
citing cause  of  this  terrible  affection,  as  injuries,  wounds,  the  presence  of 
foreign  bodies,  verminous  irritation,  the  arrest  of  natural  or  existing  dis- 
charges, and  exposure  to  heat  or  to  dampness  and  cold.  It  has  been  the  custom 
to  lay  stress  upon  the  latter  condition  as  a  powerful  causative  agent  in  mili- 
tary practice.  This  is,  however,  probably  incorrect.  It  is  not  the  degree  of 
cold  which  acts,  but  rather  exposure  to  trickling  or  changing  draughts  of  air, 
or,  as  Ilennen  has  put  it,  to  air  in  motion.  The  writer  has  known  of  instances 
where  large  numbers  of  wounded  have  at  the  same  time  been  exposed  to 
severe  cold,  without  the  development  of  a  single  case  of  the  disease,  while 
on  the  other  hand,  an  instance  was  reported  to  him  where  two,  if  not  three, 
consecutive  cases  of  tetanus  occurred  in  the  same  bed,  every  other  one  in  the 
ward  being  exempt.  The  fatal  bedstood  in  the  direct  draught  of  air  between 
a  window  and  an  opening  door,  and  on  its  removal  to  a  less  exposed  position 
no  further  instance  of  the  disease  appeared.  Tetanus  at  times  almost  seems 
to  be  epidemic,  <>r  at  all  events  t<>  affect  many  who  are  the  victims  of  casu- 
alties of  a  given  nature.  Tims  in  the  summer  of  1880,  frequent  deaths  from 
this  disease  occurred  in  Philadelphia,  and  during  1881,  in  Baltimore,  from 
the  use  of  a  toy  pistol,  which  exploded  metallic  powder  cartridges.  This 
dangerous  plaything  was  the  means  of  injuring  numerous  children  by  its  pre- 
mature and  imperfect  explosion.  In  almost  every  such  case  admitted  to  hos- 
pital, and  in  others  treated  in  private  practice,  tetanus  ensued  and  was  followed 


CAUSES  OF  DEATH  AFTER  OPERATIONS.  477 

by  death,  the  disease  often  making  its  appearance  many  days  after  the  recep- 
tion of  the  wound,  and  in  some  instances  long  after  its  closure  and  apparent 
healing. 

Erysipelas  is  a  not  infrequent  forerunner  of  death  after  operation,  and 
must  be  regarded  as  a  constitutional  rather  than  as  a  local  affection.  It  has 
long  been  the  custom  to  look  upon  it  as  contagious  ;  but  it  is  probable  that 
this  view  is  too  exclusive.  The  doctrine  is  last  gaining  ground  that  this  dis- 
ease is  not  really  contagious,  but  that  it  is  the  result  of  a  true  septic  poison 
depending  on  many  circumstances.  It,  too,  at  times  seems  to  be  epidemic, 
occurring  as  it  does,  particularly  in  this  country,  during  periods  of  rapid 
changes  In  the  weather,  and  during  atmospheric  vicissitudes.  It  is  apt  to  be 
induced  by  dampness  and  cold,  and  to  make  its  appearance  in  persons  of 
broken-down  constitution.  Its  treatment  is  essentially  a  supporting  one,  and 
general  tonics  and  iron  are  to  be  relied  upon,  rather  than  depleting  agents. 
Closely  allied  to  erysipelas,  are  those  forms  of  diffused  and  spreading  cellulitis 
and  inflammation  of  the  veins  and  absorbents  so  often  observed  in  hospital, 
following  wounds  and  operations,  on  those  of  debilitated  constitution,  and  on 
drunkards.  In  many  of  these  cases,  surgical  therapeutics  avail  little,  and 
death  from  exhaustion  ensues,  after  delusive  intervals  of  hectic  more  or  less 
prolonged.  Indeed,  exhaustion  from  long-continued  discharges,  whatever 
may  be  their  origin,  may  be  assigned  as  a  not  infrequent  cause  of  the  fatal 
termination  of  operations. 

The  disastrous  influences  of  Pyjemia  and  Septicemia  require  but  a  passing 
mention  here,  since  they  form  the  special  subjects  of  another  article.  These 
forms  of  blood-poisoning  are  met  with  most  often  in  patients  of  depraved 
system,  or  in  the  aged,  or  in  those  who  have  been  broken  down  by  overwork, 
mental  or  bodily.  "They  cause  a  large  proportion  of  the  deaths  after  opera- 
tions, and  from  their  fatal  consequences  demand  the  closest  study  from  the 
operating  surgeon. 


MINOR  SURGERY. 

BY 

CHARLES  T.  HUNTER,  M.D., 

DEMONSTRATOR  OF  ANATOMY  IN  THE  UNIVERSITY  OF  PENNSYLVANIA  J    SURGEON  TO  THE  EPISCOPAL 

HOSPITAL,  PHILADELPHIA. 


Surgical  Dressings. 

Surgical  Dressings  are  generally  considered  to  comprise  various  materials 
peculiarly  adapted  to  protect  wounds,  absorb  discharges,  serve  as  vehicles  for 
applying  medicinal  substances  to  wounded  or  diseased  structures,  aid  in 
retaining  injured  parts  in  position,  etc.  The  substances  usually  employed 
for  these  purposes  include  lint,  charpie,  tow,  oakum,  cotton,  paper-lint,  and 
jute. 

Lint. — Two  varieties  of  this  material,  domestic  and  patent,  are  used  for 
surgical  dressings.  Domestic  lint  consists  of  pieces  of  old  linen  thoroughly 
cleansed  either  by  being  washed  with  soap  and  water,  or  boiled  with  a  weak 
lye,  and  having  one  surface  rendered  downy  by  scraping  up  the  threads,  or 
cutting  them  at  intervals,  with  a  knife.  Old  linen,  treated  in  this  way,  is 
peculiarly  adapted  to  absorb  secretions  and  to  protect  very  delicate  and  sensi- 
tive surfaces. 

Patent  lint  is  manufactured  in  large  quantities  by  machinery :  hence  it  is 
more  uniform  in  shape  and  consistence  than  the  domestic  variety,  but  much 
more  expensive.  This  lint  has  a  soft  tomentose  surface  that  renders  it  un- 
suitable for  direct  contact  with  granulating  or  wounded  parts  ;  for  the  fine 
filaments  adhere  to  the  granulations,  and  thus  become  a  source  of  irritation. 
When  thickly  encased  with  some  unctuous  preparation,  such  as  the  oxide 
of  zinc  ointment,  it  forms  an  admirable  protective  covering. 

Charpie  consists  of  bundles  of  straight  threads,  varying  in  length  from 
two  to  four  inches,  and  obtained  by  ravelling  square  pieces  of  linen.  Expe- 
rience has  demonstrated  that  charpie  made  from  new  linen  is  softer  and  pos- 
sesses greater  absorbent  properties  than  that  made  from  old.  Charpie  ought 
never  to  be  placed  on  an  unprotected  granulating  surface,  or  directly  in  contact 
with  a  recent  wound,  as  is  not  infrequently  done  ;  in  either  case  its  presence 
will  excite  injurious  irritation.  Since  the  introduction  of  oakum  and  other 
less  expensive  materials  as  surgical  dressings,  charpie  is  not  as  much  used  as 
formerly,  especially  in  hospitals  and  dispensaries  where  it  is  necessary  to  con- 
sult economy. 

Tow  is  occasionally  made  use  of  as  a  padding  for  splints,  and  as  an  exterior 
dressing,  but  rarely  as  an  application  for  uncovered  wounds.  An  elegant  ] 're- 
paration of  carbolized  tow  has  recently  been  introduced,  and  has  been  found  to 
be  serviceable  in  many  ways. 

(479) 


480  MINOR   SURGERY. 

Oakum  was  introduced  as  a  cheap  substitute  for  other  more  expensive  sur- 
gical dressings,  during  the  late  American  war,  by  Prof.  L.  A.  Sayre,1  of  New 
York,  and  since  then  it  has  been  very  generally  employed  both  in  private 
and  hospital  practice  throughout  the  civilized  world.  It  is  highly  probable, 
however,  that  this  substance  has  been  often  used  for  surgical  purposes  on 
board  ship.  In  Pepys's  diary,  mention  is  made  of  a  marine  who  had  just 
returned  from  a  severe  naval,  engagement  fought  off  the  North  Foreland, 
June  1-4,  1666,  with  "his  right  eye  stopped  with  oakum."  Oakum  is 
believed  to  have  antiseptic  properties  by  virtue  of  the  tar  with  which  the 
pieces  of  old  rope  from  which  it  is  made  are  impregnated.  Formerly  this 
material  was  applied  directly  to  the  surface  of  wounds,  but  on  account  of  the 
stiffness  and  coarseness  of  its  fibres  it  has  been  found  too  irritating  for  this 
purpose.  It  is  admirably  adapted  for  use  as  an  outer  and  protective  dressing, 
and  as  padding  for  surgical  apparatus. 

Cotton,  freed  from  its  oleaginous  principle  by  being  boiled  with  alkalies  or 
otherwise  treated,  is  rapidly  coining  into  favor  as  a  surgical  dressing.  Pre- 
pared in  this  way,  it  quickly  soaks  up  the  secretions  from  a  wound,  and  is 
preferred  in  many  instances  to  oakum  or  marine  lint  as  an  outside  absorbent 
dressing.  It  may  be  medicated  with  any  of  the  popular  antiseptics,  such  as 
carbolic,  boracic,  or  salicylic  acid,  thymol,  etc.  Gynaecologists,  in  their  prac- 
tice, find  it  a  useful  means  of  making  applications  to  the  female  genital 
organs. 

Paper-Lint. — This  dressing  was  first  used  for  surgical  purposes  by  Dr. 
Studdiford,  of  Lambertville,  K".  J.  It  is  made  from  old  rags  that  have  been 
specially  prepared  and  rolled  in  sheets  of  the  requisite  form  and  size.  Dr. 
"W.  W.  Keen,  of  Philadelphia,  has  suggested  the  incorporation  of  cotton  or 
linen  threads  with  paper-pulp,  before  it  is  rolled,  in  order  that  the  lint  may  be 
rendered  more  tenacious.  As  an  application  to  the  unbroken  surface  of  the 
body,  and  as  an  absorbent,  external  dressing,  this  variety  of  lint  is  quite  as 
useful  as  patent  or  domestic  lint ;  but,  in  consequence  of  its  not  possessing  the 
softness  and  the  pliability  so  characteristic  of  linen,  it  is  not,  as  a  rule,  a 
good  substitute  for  this  material  in  the  dressing  of  wounds.  Its  cheapness 
in  comparison  with  the  high  cost  of  patent  lint  recommends  it  for  hospital 
and  dispensary  use. 

Jute. — This  substance,  of  which  gunny  bags  are  made,  is  the  fibre  of  an 
Indian  annual,  the  Corchoms  capsularis.  In  consequence  of  the  peculiar 
character  of  its  fibres,  it  is  well  adapted  for  the  absorption  and  the  retention 
of  the  various  antiseptics  ;  this  property,  and  its  cheapness  in  comparison 
with  gauze  and  surgical  cotton,  have  recommended  its  use  as  an  antiseptic 
medium,  to  many  of  the  advocates  of  Listerism.  Jute  may  be  employed  with 
advantage  as  an  absorbent  dressing  in  all  cases  in  which  oakum  or  cotton  is 
used  ;  rolled  loosely  in  small  masses,  it  is  considered  in  hospital  and  military 
practice  a  good  substitute  for  sponges  by  those  surgeons  who  believe  that  the 
use  of  these  may  result  in  the  infection  of  wounds. 

To  meet  a  great  variety  of  indications  in  the  treatment  of  wounds,  sur- 
l:<'(>iis  are  accustomed  to  make  the  following  forms  of  dressing  froin  the  sub- 
stances  already  described. 

COMPRESSES  are  usually  made  by  folding;  pieces  of  lint,  flannel,  paper-lint, 
or  muslin,  upon  themselves,  so  as  to  form  firm  masses  of  varying  size;  these 

1   Boston  Medical  and  Surgical  Journal,  vol.  lxvii.  p.  84. 


SURGICAL   DRESSINGS.  481 

may  be  made  square,  oblong,  triangular,  or  graduated  in  shape.  When  a 
compress  has  a  hole  in  its  centre,  it  is  termed  a  perforated  compress ;  if 
there  are  many  perforations,  it  is  called  a  cribriform  compress.  JLjpyramidal 
compress  is  constructed  by  placing  a  series  of  square  compresses,  gradually 
diminishing  in  size,  upon  one  another,  in  such  a  way  as  to  form  a  pyramid. 
Oblong  compresses  arranged  in  the  same  serial  order  make  a  prismatic  com- 
press. A  square  piece  of  lint  or  muslin,  slit  from  its  angles  towards  the  cen- 
tre, forms  a  Maltese  cross ;  an  oblong  piece,  with  slits  extending  from  the 
angles  of  one  side  obliquely  towards  the  opposite  side,  is  called  a  half  Mal- 
tese cross.  These  two  forms  of  compress  are  found  of  service  in  covering  the 
end  of  a  stump,  or  in  retaining  dressings  in  contact  with  it. 

The  Pledget  is  a  form  of  compress  consisting  of  charpie,  oakum,  or  jute, 
the  fibres  of  which  are  arranged  in  a  direction  parallel  to  one  another ;  after 
the  ends  are  folded  down,  the  mass  is  flattened  between  the  hands,  and 
fashioned  into  the  required  shape,  either  square,  oblong,  pyramidal,  or 
graduated.  Constructed  in  this  manner,  pledgets  are  applied  as  external 
dressings  to  wounds,  extremities  of  stumps,  and  ulcers,  for  the  purpose  of 
absorbing  discharges  and  excluding  the  air,  and  in  some  instances  to  make 
compression,  and  to  aid  in  giving  fixity  to  other  dressings. 

The  Tent  is  a  small  roll  of  either  of  the  substances  referred  to  in  the  last 
paragraph,  doubled  upon  itself,  and  made  to"  assume  a  conical  shape  by 
twisting  its  free  ends  between  the  thumb  and  fingers.  A  strip  of  lint  or 
muslin  is  often  used  for  the  same  purpose.  Tents  made  in  this  way  are  de- 
signed in  special  cases  to  keep  wounds  patulous,  and  thus  to  afford  a  ready 
escape  to  discharges.  A  tent  should  be  introduced  into  a  wound  by  a  rotary 
motion,  having  previously  been  smeared  with  some  bland,  unctuous  substance. 

The  Meche  is  made  by  twisting  a  mass  of  parallel  threads  of  charpie  at  the 
middle ;  if  the  threads  are  tied  together  with  a  string,  the  mass  is  called  a 
Roll.  These  dressings,  anointed  with  olive  oil  or  simple  cerate,  and  placed 
in  the  track  of  a  sinus  or  fistula  that  has  been  laid  open,  will  delay  union  of 
its  edges  till  the  deeper  part  has  granulated.  Hemorrhage  from  a  deep  wound 
may  be  checked  by  pressing  a  meche  or  roll  down  to  the  bottom ;  the  central 
part  of  the  mass  will  compress  the  bleeding  vessels,  and  the  loose  end  will 
favor  the  formation  of  a  clot.  Meches  and  rolls  are  introduced  into  a  wound 
by  means  of  a  poiie-meche  (Fig.  40),  director,  or  probe,  placed  against  the 
compact  centre  of  the  mass. 

Fig.  40. 

1 


GEMRIG  &S0N.  PHIL, 
Porte-m&che. 


Pellets  and  Bullets  are  small  masses  of  charpie,  oakum,  cotton,  or  jute, 
rolled  loosel}T  between  the  palms  of  the  hands.  The  former  differ  from  the 
latter  only  in  being  inclosed  in  small  bags  of  linen  or  old  muslin.  They  may 
be  usefully  employed  as  tampons  in  cases  of  wounds,  to  check  bleeding,  and 
may  be  introduced  into  suppurating  cavities  for  the  purpose  of  absorbing  pus 
and  preventing  burrowing. 

Retractors  are  strips  of  muslin  designed  to  protect  soft  tissues  from  being- 
injured  b}r  the  saw  in  amputations.      The  retractor  of  two  tails  is  an  oblong 
piece  of  muslin,  ten  to  fifteen  centimetres  (four  to  six  inches)  wide,  and  thirty 
to  forty-five  centimetres  (twelve  to  eighteen  inches)  long,  with  a  slit  extend- 
vol.  i. — 31 


482  MINOR   SURGERY. 

ing  from  one  extremity  to  the  centre,  where  a  diamond-shaped  piece  is  cut 
out.  The  retractor  of  three  tails  is  of  the  same  size  as  the  preceding,  but  has 
three  tails  instead  of  two.  The  former  is  used  in  amputations  of  the  arm 
and  thigh.  After  the  flaps  have  been  fashioned  and  the  soft  parts  divided, 
the  retractor  is  applied  by  passing  the  tails  one  on  either  side  of  the  bone,  and 
crossing  them ;  then  by  drawing  the  tails  up  on  one  side  and  the  body  of  the 
retractor  on  the  other,  the  flaps  are  held  out  of  the  way  of  the  saw,  and  pro- 
tected from  the  bone-dust.  The  three-tailed  retractor  is  employed  in  ampu- 
tations of  the  forearm  and  leg ;  the  middle  tail  is  passed  through  the  inter- 
osseous space,  and  the  other  two  are  carried  around  the  bones. 

To  get  the  greatest  advantage  from  the  use  of  wet  dressings,  in  cases  in  which 
heat  and  moisture  are  indicated,  it  is  necessary  that  the  dressings  shall  be 
covered  with  some  material  impervious  to  water.  The  following  substances 
possess  this  property  to  a  greater  or  less  degree  :— 

Oiled  Silk  and  Gutta  Percita  or  Rubber  Tissue,  are  the  substances  most 
commonly  used  in  private  practice;  the  former  in  this  country  and  the  latter 
in  England.  Although  these  two  substances  make  the  best  water-proof  covers 
for  moist  dressings,  yet  their  great  cost,  and  the  supposed  risk  of  their  be- 
coming media  of  contagion  if  used  more  than  once,  have  led  to  the  substitu- 
tion of  other  less  expensive  articles,  viz.,  waxed  paper  and  water-proof  paper. 

Waxed  Paper  was  first  suggested  and  used  in  the  Pennsylvania  Hospital, 
by  Dr.  A.  Hewson.1  It  is  prepared  by  placing  a  sheet  of  tissue  paper  on  the 
surface  of  melted  wax  in  a  broad,  shallow  pan,  and,  before  the  paper  sinks  in 
the  wax,  slowly  drawing  it  over  the  edge  of  the  pan,  in  order  that  the  super- 
fluous wax  may  be  removed  from  its  under  surface.  The  sheets  of  paper  thus 
treated  are  suspended  on  cords  for  a  few  hours  in  a  cool  place ;  after  which 
they  are  ready  for  use.  A  sand-bath  is  employed  to  keep  the  wax  in  a  liquid 
state. 

Water-proof  Paper. — Dr.  W.  W.  Keen,  of  Philadelphia,2  has  devised  a 
method  of  preparing  paper  by  which  it  is  rendered  impervious  to  water 
and  air.  The  paper  is  treated  with  a  combination  of  rubber  and  paraffine 
which  makes  it  impermeable  to  water  for  a  period  of  seventy-two  hours,  and 
it  may  be  used  with  the  hottest  dressing  that  can  be  borne.  Unlike  waxed 
paper,  its  water-proof  property  is  not  in  the  least  affected  b}T  being  creased 
or  crumpled,  nor  will  it  absorb  either  water  or  the  discharges  from  a  wound. 
It  is  asserted  by  some  surgeons  that  in  hospitals  where  large  quantities  of 
water-proof  material  are  concerned,  it  has  been  found  more  economical  to  use 
water-proof  paper  than  oiled  silk  or  rubber  tissue,  even  when  the  former  is 
not  used  a  second  time. 

In  order  that  wounds  maybe  treated  strictly  antiseptically,  two  substances, 
made  impervious  both  to  the  discharges  from  the  wounds  and  to  the  surround- 
ing media,  are  essential:  one  to  protect  the  wound  itself  from  contact  with 
the  dressing  ;  the  other  to  prevent  putrefactive  germs  from  gaining  access  to 
the  dressing  as  it  becomes  saturated  with  the  discharges. 

The  Protective.3 — This  material  is  to  be  placed  in  direct  contact  with  the 
wound.     It  consists  of  oiled  silk  coated  on  both  sides  with  a  thin  layer  of 

■  Pennsylvania  Hospital  Reports,  1868,  p.  389. 

2  Medical  and  Surgical  Reporter,  vol.  xl.,  1879,  p.  331. 

3  MaeCormac,  Antiseptic  Surgery,  p.  135. 


THE   USE   OF   BANDAGES.  483 

copal  varnish,  and,  when  dry,  brushed  over  "with  a  solution  containing  one 
part  of  dextrine  and  two  of  starch,  dissolved  in  fifteen  parts  of  five  per  cent, 
carbolic  solution."  Immediately  before  using  the  protective,  it  is  to  be  dipped 
in  a  1-40  carbolic  acid  solution,  in  order  that  no  germs  may  be  left  adhering  to 
it.  The  same  piece  of  protective  may  be  used  several  times  if  it  be  properly 
disinfected. 

Mackintosh. — This  substance  consists  of  cotton  or  silk,  made  impermeable 
to  water  and  air  by  being  coated  on  one  or  both  sides  with  India-rubber. 
Other  substances,  among  which  are  rubber-tissue  and  oiled  paper,  have  been 
employed  as  substitutes  for  mackintosh,  but  they  have  proved  less  efficient. 
It  is  placed  external  to  the  gauze-dressing,  and  may  be  secured  by  a  gauze- 
bandage,  or  by  an  elastic  bandage,  which  Mr.  Lister  occasionally  uses  now.  A 
piece  of  mackintosh  may  be  repeatedly  used,  if  care  be  taken  to  clean  and 
disinfect  it  thoroughly  each  time  that  it  is  applied. 


The  Use  of  Bandages. 

"Roller  Bandages. — The  Roller  consists  of  a  band  or  strip  of  woven  mate- 
rial, prepared  for  application  to  some  portion  of  the  body  by  being  rolled  into 
cylindrical  form.  The  materials  commonly  used  are  unbleached  muslin  and 
flannel ;  for  special  purposes,  however,  linen,  calico,  silk,  India-rubber,  or 
crinoline,  may  be  selected.  It  is  desirable  that  a  bandage  should  consist  of  a 
single  piece,  free  from  seams  and  selvage ;  yet  bandages  are  sometimes  made 
of  several  pieces  sewed  together.  The  latter  should  be  avoided  if  possible 
whenever  it  is  necessary  to  apply  a 
bandage  next  to  the  integuments,  for  Flg" 

the  seams  (and  the  same  is  true  of  sel-  """"X^,^'-^ -- 

vage)  will  leave    creases   in  the  skin.  /  /     Mm!i&Ds§StL 

Bandages  vary  greatly  in  length  and  /■; 

width  according  to  the  purposes  for  >\ 

which  they  are  employed,  ranging 
from  2  to  10  centimetres  (f  of  an  inch 
to  4  inches)  in  width,  and  from  18^- 
to  91  decimetres  (2  to  10  yards)  in 
length.  Bandages  may  be  rolled  by 
hand,  or  with  a  machine  called  a  winder 
(Fig.  41),  which  is  commonly  used  in 
hospitals  where  large  quantities  of 
bandages  are  consumed.  In  private 
practice  a  medical  attendant  may  be 

x    -,1     -,  .  .      .  u .,  Bandage  winder. 

called  upon,  at  any  moment,  to  roll  a 

bandage ;  hence  the  art  of  rolling  one  by  hand,  which  may  be  readily  ac- 
quired with  slight  practice,  should  be  familiar  to  every  physician.  In  Fig. 
42  is  illustrated  the  way  in  which  a  roller  is  to  be  held  in  winding  it  by  hand. 
A  bandage  rolled  into  the  form  of  a  cylinder  is  called  a  single,or  single-headed 
roller  (Fig.  43);  if  rolled  from  each  extremity  towards  the  centre,  into  two 
round  masses,  it  forms  a  double,  or  double-headed  roller.  (Fig.  44.)  The  latter 
form  of  roller  is  hardly  ever  used. 

Parts  of  a  Roller. — The  free  end  of  a  roller  is  termed  the  initial  extremity  ; 
the  end  inclosed  in  the  centre  of  a  roller  is  its  terminal  extremity;  the  portion 
intervening  between  the  extremities,  the  body  ;  a  roller  has  two  surfaces,  ex- 
ternal and  internal.  Bandages  derive  their  names  from  one  of  two  circum- 
stances, either  from  the  direction  that  they  are  made  to  take  when  applied, 


484 


MINOR   SURGERY. 

Fig.  42. 


Mode  of  rolling  a  bandage  by  hand. 

or  from  the  purposes  subserved  by  them.  Thus  there  are  circular,  oblique, 
spiral,  spica,  figure-of-eight,  and  recurrent  bandages  of  the  first  kind ;  and  re- 
taining, compressing,  uniting,  dividing,  etc.  of  the  second. 


Fie.  43. 


Fnr.  44. 


Single-headed  roller. 


Double-headed  roller. 


General  Rules  for  Bandaging. — The  operator,  as  a  rule,  should  stand 
with  his  face  towards  his  patient,  and  before  he  begins  to  bandage  any  part — 
a  limb,  for  instance — he  should  see  that  it  is  in  the  position,  as  regards  flexion 
and  extension,  which  it  is  to  occupy  after  the  bandage  is  applied.  In  the 
application  of  a  bandage,  the  external  surface  of  the  initial  extremity  should 
be  placed  next  to  the  pari  to  be  covered;  for  then,  as  the  bandage  is  unwound, 
it  tends  to  roll  into  the  operator's  hand,  thereby  giving  him  more  control 
of  it. 

To  Secure  a  Bandage. — The  initial  extremity  of  a  bandage  is  secured  by 
two  or  three  circular  turns ;  the  terminal  end  may  be  fastened  by  one  or  two 
pins,  or  by  tearing  it  into  two  tails  and  tying  them  around  the  part.  (See 
Pig.  49.)  When  pins  are  u<c<\  to  fix  the  terminal  extremity,  they  may  be 
introduced,  either  transversely  to  the  bandage,  with  the  point  directed  down- 


THE   USE   OF   BANDAGES. 


485 


wards,  or  longitudinally,  with  the  point  looking  towards  the  body  of  the 
bandage ;  in  either  case  the  point  should  be  buried  in  the  bandage. 

To  Remove  a  Bandage. — In  taking  off  a  bandage,  the  folds  should  be  care- 
fully gathered  up  in  a  loose  mass  as  the  bandage  is  unwound ;  this  will  facilitate 
the  process,  and  prevent  the  part  from  becoming  entangled  in  the  loops. 


Fie.  45. 


Special  Bandages.  The  Circular  Bandage. — This  consists 
turns  around  a  part,  each  turn  accurately  covering  in  the  w 
ceding.  (Fig.  45,  a.)  Its  use  is 
to  retain  dressings  on  some  part 
of  the  vault  of  the  cranium,  and 
on  the  neck;  and  to  compress 
the  veins  above  the  elbow,  as  a 
preliminary  step  in  venesection. 

Tlie  Oblique  Bandage. — This 
bandage  is  carried  by  oblique 
turns  up  a  limb,  leaving  uncov- 
ered spaces  between  the  succes- 
sive turns.  It  is  used  to  retain 
temporary  dressings.  (See  Fig. 
45,  b.) 

The    Spiral    Bandage. — The 
turns  of  this  bandage  are  carried 
around  a  part  in  a  spiral  direc- 
tion, with  each  turn  overlapping 
a  portion  of  the  preceding,  usu- 
ally one-third  or  one-half.     (See 
Fig.    45,   c.)     This   bandage   is 
used   for  all    the  purposes  for 
which  that  to  be  next  de- 
scribed    is     employed,    on 
parts     the    dimensions     of 
which  do  not  vary. 

The  Spiral  Reversed  Band- 
age.— This  bandage  differs 
from  the  preceding  in  hav- 
ing its  turns  folded  back,  or 
reversed,  as  it  ascends  a  limb 
the  diameter  of  which  grad- 
ually increases.  This  modi- 
fication of  the  spiral  is  of  the 
utmost  importance,  for  with 
it  spiral  turns  can  be  applied 
to  a  limb  conical  in  shape, 
so  as  to  make  equable  pres- 
sure on  all  parts  of  the  sur- 
face. Reverses  may  be  form- 
ed in  the  following  manner: 
After  the  initial  extremity 
of  a  roller  is  made  fast  by  a 
couple  of  circular  turns,  the 
roller  is  carried  off  ten  or 
thirteen  centimetres  (four  or 
five  inches)  from  the  limb,  at 

an    aCUte     angle;     the    index  Mode  of  making  reverses. 


of  a  few 
hole  of 


circular 

the  pre- 


a  circular,  b  oblique,  and  c  spiral  turns  of  bandage. 


Fig.  46. 


486  MINOR   SURGERY. 

finger  or  thumb  of  the  disengaged  hand  is  put  on  the  body  of  the  bandage  to 
keep  it  securely  in  place  on  the  limb,  while  the  reverse  is  being  made;  then 
the  hand  holding  the  roller  is  carried  a  little  towards  the  limb,  to  slacken  the 
unwound  portion,  and,  by  changing  the  position  of  this  hand  from  extreme 
supination  to  pronation,  the  reverse  is  made.  (Fig.  46.)  A  reverse  must 
be  completed  before  the  bandage  is  continued  round  the  limb ;  for  if  traction 
be  made  while  the  reverses  are  being  formed,  the  bandage  will  be  twisted  and 
corded,  and  will  consequently  become  a  source  of  annoyance,  if  not  of  positive 
suffering,  to  the  patient.  For  a  bandage  to  present  a  neat  and  finished  ap- 
pearance, its  reverses  should  be  in  line  with  one  another.  Reverses  ought 
never  to  be  made  over  a  salient  portion  of  the  skeleton  if  it  can  be  avoided. 

Spiral  Bandages. — The  Spiral  Beversed  of  the  Upper  Extremity. — A  roller 
bandage  6 \  centimetres  (2J  inches)  wide  and  6J  metres  (7  yards)  long.  First 
fix  the  initial  extremity  at  the  wrist  by  two  circular  turns ;  then  carry  the 
roller  obliquely  across  the  back  of  the  hand  to  the  second  joints  of  the  fingers, 
and  surround  them  by  a  circular  turn ;  ascend  the  hand  as  far  as  the  thumb 
by  one  or  two  spiral  turns;  on  reaching  the  thumb,  cover  its  base  and  the 
wrist  by  two  figure-of-eight  turns  carried  above  and  below  the  thumb,  and 
then  continue  up  the  forearm  to  the  elbow  by  spiral  reversed  turns,  made  on 
the  anterior  aspect  of  the  forearm.  The  elbow  may  be  covered  by  spiral, 
spiral  reversed,  or  iigure-of-eight  turns  (passing  above  and  below  the  joint, 
and  named  from  their  appearance),  according  to  circumstances.     When  it  is 

Fig.  47. 


Spiral  reversed  bandage  of  the  upper  extremity. 

desirable  to  permit  motion  at  this  joint,  the  latter  form  of  bandage  is  em- 
ployed, and  is  applied  with  the  joint  somewhat  flexed.  To  complete  this 
roller  it  is  conducted  up  the  arm  by  spiral  reversed  turns  to  the  margin  of 
the  axilla,  where  its  terminal  end  is  secured  by  a  pin.     (Fig.  47.) 

The  Spiral  of  a  Finger. — A  roller  2  centimetres  (f  of  an  inch)  wide  and  1\ 
metres  (\\  yards)  long.  After  securing  the  initial  end  by  two  circular  turns 
at  the  wrist,  conduct"  the  bandage  obliquely  over  the  dorsum  of  the  hand  to 
the  base  of  the  finger  that  is  to  be  covered  ;  thence  to  its  distal  extremity  by 
oblique  turns;  ascend  the  finger  by  spiral  turns,  and,  on  reaching  its  proximal 
end,  carry  the  bandage  obliquely  across  the  back  of  the  hand,  and  terminate 
ii  by  a  couple  of  turns  around  the  wrist;  either  pin  the  extremity  of  the 
roller,  or  divide  it  in  two  tails  and  tie  them  around  the  joint.     (Fig.  48.) 

The  Spiral  of  the  Rand,  or  the  Demi-Gauntlet. — A  roller  2|  centimetres  (1 
inch)  wide  and'Sy  metres  C-'>  yards)  long.  The  initial  extremity  is  first  secured 
by  two  circular  turns  around  the  wrist,  after  which  the  roller  is  carried  from 
one  side  of  the  wrist  to  the  opposite  side  of  the  hand  obliquely  across  either 
the  dorsum  or  the  palm,  the  direction  being  determined  by  that  surface  of 
the  hand  which  is  to  be  covered  ;  from  this  point  the  bandage  is  wound  around 


SPIRAL    BANDAGES. 


487 


the  base  of  the  finger  and  taken  back  to  the  wrist,  making  a  figure-of-eight 
of  the  finger  and  wrist.  A  figure-of-eight  turn  is  made  in  like  manner  around 
the  base  of  each  finger  and  the  wrist  in  succession,  and  the  roller  is  finally 
fastened  at  the  wrist.  (Fig.  49.)  This  bandage  is  admirably  adapted  to  con- 
fine dressings  to  either  surface  of  the  hand,  as  occasion  may  require  ;  it  is  less 
cumbersome,  and  retains  a  dressing  with  more  security,  than  any  other  means 
used  for  the  same  purpose. 


Fig.  48. 


Spiral  bandage  of  a  finger. 


Spiral  bandage  of  the  hand,  or  demi-gauntlet. 


The  Spiral  Reversed  Bandage  of  the  Lower  Extremity. — Two  rollers,  each 
6J-7T7-g-  centimetres  (2|-3  inches)  wide  and  6 h  metres  (7  yards)  long.  The 
initial  end  being  secured  just  above  the  malleoli  by  two  circular  turns,  the 
roller  is  carried  obliquely  across  the  dorsum  of  the  foot,  and,  on  reaching  the 
metatarso-phalangeal  articulation,  is  conducted  directly  around  the  foot;  the 
body  of  the  foot  is  now  covered  by  two  spiral  reversed  turns  and  the  same 

Fig.  50. 


Spiral  reversed  bandage  of  the  lower  extremity. 

number  of  figure-of-eight  turns,  the  latter  being  around  the  ankle  and  instep, 
and  the  roller  is  then  continued  up  to  the  knee  by  spiral  reversed  turns,  each 
turn  covering  one-third  of  the  preceding  ;  the  reverses  should  be  in  a  line  on 
the  outer  side  of  the  spine  of  the  tibia.  As  in  the  case  of  the  elbow,  the  knee 
may  be  covered  by  spiral,  spiral  reversed,  or  figure-of-eight  turns.  If  it  be  de- 
signed to  keep  the  knee  flexed,  the  figure-of-eight  turns  should  be  employed. 
From  the  knee  the  roller  is  conducted  up  the  thigh  by  spiral  reversed  turns, 
and  is  secured  by  pins.  The  second  roller  is  used  for  the  knee  and  the  thigh. 
(Fig.  50.), 

A  modification  of  this  bandage  is  occasionally  employed  to  cover  the  heel, 
and  is  known  as  the  American  Spiral  in  contradistinction  to  that  just  de- 
scribed, which  is  sometimes  called  the  French  Spiral.  The  turns  by  which 
the  heel  is  included  are  made  in  the  following  manner:  After  the  foot  is  cov- 
ered by  two  or  three  spiral  turns,  the  bandage  is  carried  directly  over  the 
point  of  the  heel,  across  the  tarsal  portion  of  the  foot,  thence  beneath  the  in- 
step, around  one  side  of  the  heel  and  up  over  the  instep  again  ;  from  this  point 
it  is  conducted  beneath  the  instep,  around  the  other  side  of  the  heel  and  up 


488 


MINOR   SURGERY. 


in  front  of  the  ankle,  from  which  it  may  be  made  to  ascend  the  leg,  as  in  the 
preceding  bandage.     (Figs.  51,  52.) 

The  Spiral  Bandage  of  the  Chest. — A  roller  7f— 9  centimetres  (3-3J  inches) 
wide,  and  9^-  meties  (10  yards)  long.     Make  two  circular  turns  around  the 


Fig.  51. 


Fig.  52. 


Fig.  53. 


American  spiral  of  the  lower  extremity. 

waist,  to  secure  the  initial  extremity  of  the  roller,  and  then  ascend  the  chest 
by  spiral  or  spiral  reversed  turns,  each  turn  overlapping  one-third  of  the  pre- 
ceding ;  when  the  borders  of  the  axillae  are  reached,  conduct  the  roller  around 
the  base  of  the  neck,  or  through  one  axilla  and  over  the  corresponding  shoul- 
der, obliquely  down  the  anterior  aspect  of  the  thorax.  If  this  longitudinal 
strip  be  pinned  or  stitched  to  the  spiral  turns  at  their  intersections,  the  bandage 
will  not  be  easily  disarranged. 

The  Spiral  Bandage  of  the  Penis. — A  roller  2  centimetres  (f  of  an  inch)  wide 
and  |  of  a  metre  (30  inches)  long.     Secure  the  initial  end  of  the  roller  by  two 

circular  turns  around  the  penis,  close  to  the  pubes, 
and  conduct  the  bandage  by  oblique  turns  to  the 
corona  glandia  ;  from  this  point  ascend  the  body 
of  the  penis  by  spiral  or  spiral  reversed  turns; 
then  make  two  or  three  figure-of-eight  turns 
around  the  neck  of  the  scrotum  and  the  root  ol 
the  penis,  and  secure  the  terminal  extremity  by 
dividing  it  in  two  strips  and  tying  them  around 
the  root  of  the  penis.  (Fig.  53.)  The  terminal 
figure-of-eight  turns  of  this  bandage  keep  it 
securely  in  position,  and  thus  render  it  a  very 
useful  means  of  compressing  the  urethra  over  a 
catheter  or  bougie,  in  cases  of  obstinate  hemor- 
rhage from  the  penile  portion  of  this  canal. 

Spica  Bandages. — These  bandages  are  exceed- 
ingly serviceable  as  a  means  of  retaining  surgical 
dressings  on  particular  parts  of  the  surface  of  the 
body,  for  which  the  spiral  rollers  are  not  well 
adapted.  They  derive  their  name  from  their 
fancied  resemblance  to  a  spike  of  barley. 


SPICA   BANDAGES. 


489 


The  Spica  Bandage  of  the  Thumb. — A  roller  2  centimetres  (f  of  an  inch) 
wide  and  2f  metres  (3  yards)  long.  Fasten  the  initial  extremity  by  one  or 
two  circular  turns  at  the  wrist,  then  carry  the  roller  obliquely  over  the  dor- 
sum of  the  thumb  to  its  distal  extremity,  and  there  make  a  circular  turn ; 
from  this  point  conduct  the  roller  obliquely  over  the  back  of  the  thumb  to 
the  wrist,  around  which  make  another 

circular  turn;   then  carry  the  bandage  Fig.  54. 

in  a  figure-of-eight  form  around  the 
thumb  and  back  again  to  the  wrist. 
These  turns  overlapping  one  another  by 
half  or  two-thirds  of  their  width,  are 
repeated  till  the  whole  length  of  the 
thumb  is  enveloped.    (Fig.  54.) 


Spica  bandage  of  the  thumb. 


The  Spica  Bandage  of  the  Shoulder* — 
A  roller  6  J  centimetres  (2|  inches)  wide 
and  6f  metres  (7  yards)  long.  Fix  the 
initial  extremity  by  two  circular  turns  around  the  arm  just  below  the  mar- 
gin of  the  axilla ;  carry  the  roller  from  the  outer  surface  of  the  arm,  if  on  the 
right  side,  obliquely  across  the  front  of  the  chest ;  if  on  the  left  side,  obliquely 
over  the  back  ;  through  the  opposite  axilla  and  back  to  the  shoulder  from 
which  the  bandage  was  started,  there- 
by completing  the  first  spica ;  then  Fig-  55. 
conduct  the  roller  around  the  arm  of 
this  side,  up  over  the  shoulder,  across 
the  thorax,  through  the  axilla  the 
second  time,  and  back  to  the  shoulder 
again.  Repeat  the  turns  in  like  man- 
ner, over  the  shoulder  and  through  the 
opposite  axilla,  till  the  former  is  cov- 
ered ;  after  which  conduct  the  terminal 
end  around  the  neck  and  down  the 
front  of  the  chest  where  it  may  be  se- 
cured by  a  pin.  Where  the  turns  of 
the  bandage  intersect  on  the  shoulder, 
they  should  overlap  one  another  to 
the  extent  of  one-third  of  their  width ; 
in  the  opposite  axilla,  however,  they 
should  completely  cover  one  another. 
(Fig.  55.)  When  the  intersections  or 
spicas  advance  successively  from  the 
point  of  the  shoulder  to  the  base  of 
the  neck,  the  bandage  is  called  the 
ascending  spica.  If  the  succession  of 
the  spica  be  in  the  reverse  direction, 
that  is,  from  the  neck  towards  the 
arm,  the  roller  is  termed  the  descend- 
ing spica.  Small  masses  of  cotton,  oakum,  or  jute,  should  be  interposed  be- 
tween the  borders  of  the  axilla  and  the  turns  of  the  bandage  to  prevent 
excoriation. 


Spica  bandage  of  the  shoulder. 


The  Spica  Bandage  of  the  Groin. — A  roller  74  centimetres  (3  inches)  wide 
and  9|-  metres  (10  yards)  long.  Secure  the  initial  end  by  two  circular  turns 
around  the  body,  just  above  the  pelvis  ;  then  carry  the  roller  obliquely  down- 
wards across  the  lower  part  of  the  abdomen,  either  to  the  outer  side  of  the 


490 


MINOR    SURGERY. 


left  thigh,  or  to  the  inner  side  of  the  right,  as  the  case  may  be;  thence  around 
the  thigh,  obliquely  upwards,  crossing  the  preceding  turn,  and  around  the 
body.  Continue  these  turns  around  the  thigh  and  abdomen,  either  in  an  as- 
cending or  a  descending  order  as  regards  the  thigh,  till  the  roller  is  exhausted. 
Each  turn  around  the  thigh  should  overlap  that  immediately  preceding  by 
one-third  of  its  width.  If  the  intersection  of  the  turns  on  the  anterior  surface 
of  the  thigh  and  the  groin  be  from  above  downwards,  a  descending  spicu  will 
be  formed ;  if  they  be  in  the  reverse  direction,  that  is,  from  below  upwards, 
an  ascending  spica  will  be  made.  (Fig.  56.) 


Fig.  56. 


Fig.  57. 


Spica  bandage  of  the  groin. 


Spica  bandage  of  both  groins. 


The  Spica  Bandage  of  both  Groins. — Two  rollers,  each  74  centimetres  (3 


inches)  wide  and  6f  metres  (7  yards)  long. 
Fig.  58. 


Spica  bandage  of  the  foot. 


This  bandage  is  begun  like  the 
preceding,  by  two  circular  turns 
above  the  ilia,  after  which  a 
spica  turn  is  made,  as  above  de- 
scribed, first  on  one  thigh  and 
then  on  the  other,  either  in  an 
ascending  or  a  descending  series. 
(Fig.  57.) 

The  Spica  Bandage  of  the 
Foot,  sometimes  called  Ribbail's 
Bandage.  A  roller  5  centime- 
tres (2  inches)  wide  and  Of  me- 
tres (7  yards)  long.  Make  fast 
the  initial  end  of  the  roller,  laid 
obliquely  upwards  on  the  dor- 
sum of  the  foot,  by  a  circular 
turn  around  the  metatarst (-pha- 
langeal articulation,  and  one  or 
two  spiral  reversed  turns  around 


FIGURE-OF-EIGHT    BANDAGES. 


491 


the  metatarsus ;  then  carry  the  bandage  parallel  with  the  inner  or  outer 
margin  of  the  sole  of  the  foot,  according  to  whether  it  be  the  right  or  left 
foot,  directly  across  the  posterior  surface  of  the  heel,  thence  along  the  oppo- 
site border  of  the  foot  and  over  the  dorsum ;  this  completes  one  spica  turn. 
From  the  dorsum  the  bandage  is  made  to  encircle  the  foot  and  pass  around 
the  heel  and  over  the  foot  the  second  time,  thereby  forming  another  spica  on 
the  foot.  By  continuing  these  successive  turns  around  the  foot  and  the 
heel,  each  complete  turn  overlapping  one-half  or  two-thirds  of  the  preceding, 
in  an  ascending  order,  the  entire  foot  and  ankle  are  covered.  (Fig.  58).  In 
all  cases  in  which  firm  compression  of  the  foot  is  indicated,  as  in  bruises, 
chronic  sprains,  wounds  of  the  tibial  vessels,  etc.,  this  neat  bandage  will  be 
found  of  great  advantage. 

Figure-of-Eight  Bandages. —  The  Figure-of-Eight  Bandage  of  the  Elboic. — 
A  roller  6 \  centimetres  (2 h  inches)  wide  and  If  metres  (lh  yards)  long.  Fix 
the  end  of  the  roller  by  two  circular  turns  around  the  upper  part  of  the  fore- 
arm, then  carry  it  obliquely  across  the  bend  of  the  elbow  to  the  arm,  above 
the  inner  or  outer  condyle  according  to  the  direction  taken,  thence  over  the 
posterior  surface  of  the  arm  to  the  opposite  side,  and  across  the  front  of  the 
elbow  again,  to  the  point  from  which  the  roller  started.  These  turns  are  re- 
peated, making  those  above  the  joint  overlap  the  lower  thirds  of  the  preceding 
turns,  and  those  below,  the  upper  thirds,  till  the  point  of  the  elbow  is  reached; 
then  complete  the  envelopment  of  the  joint  by  a  circular  turn  carried  over 
the  olecranon  process.  This  bandage,  when  it  does  not  form  a  constituent 
part  of  the  spiral  reversed  of  the  upper  extremity,  is  principally  used  to  retain 
a  compress  or  other  dressing  on  the  wound  made  in  venesection  at  the  bend 
of  the  elbow. 


The  Anterior  Figure-of-Eight  Bandage  of  the  Chest. — A  roller 
metres  (2|  inches)  wide  and 
6f-  metres  (7  yards)  long. 
Make  fast  the  initial  extre- 
mity by  two  circular  turns 
around  the  upper  part  of 
the  right  arm,  after  which 
cany  the  roller  over  the 
shoulder,  obliquely  across 
the  front  of  the  thorax, 
through  the  left  axilla, 
over  the  shoulder  of  the 
same  side,  thence  back 
across  the  front  of  the 
chest  (intersecting  the  pre- 
ceding turn  over  the  ster- 
num) through  the  right 
axilla,  and  up  to  the  top 
of  the  shoulder.  Repeat 
the  figure-of-eight  turns  on 
the  anterior  face  of  the 
chest,  till  the  bandage 
runs  out,  and  pin  the  ter- 
minal end.  The  borders 
of  both  axilke  should  be 
protected  from  excoriation 

by  compresses  of  cotton  or  jute,  inserted  between  them  and  the  tur 
bandage.  (Fig.  59.) 


6 J  centi- 


Anterior  figure-of-eight  bandage  of  the  chest. 


ns  of  the 


492 


MINOR   SURGERY. 


The  Posterior  Figure-of-eight  Bandage  of  the  Chest. — A  roller  6J  centimetres 
(2|  inches)  wide  and  6f  metres  (7  yards)  long.  Secure  the  initial  end  of  the 
roller  on  the  upper  part  of  the  left  arm  by  two  circular  turns,  then  conduct 
the  bandage  over  the  shoulder,  obliquely  across  the  back,  through  the  oppo- 
site axilla,  over  the  shoulder  of  the  same  side,  obliquely  across  the  posterior 
surface  of  the  thorax  (crossing  the  previous  turn  between  the  scapulae),  through 
the  left  axilla,  and  up  to  the  summit  of  the  shoulder,  from  which  similar 
turns  across  the  back  and  through  the  axilla  are  to  be  repeated  till  the  band- 
age is  exhausted.  (Fig.  60.)  The 
same  precautions  against  excoriation 
of  the  borders  of  the  axilla?  are  to 
be  adopted  as  in  the  case  of  the  pre- 
ceding bandage. 

The  Suspensory  and  Compressor 
Bondage  of  the  Breast.  —  A  roller 
6^-7f  centimetres  (2J-3  inches) 
wide  and  7t3q--9/¥  metres  (8-10 
yards)  long.  Make  fast  the  initial 
end  of  a  roller,  placed  over  the  sca- 
pula of  the  aflected  side,  by  two 
oblique  turns  carried  over  the  oppo- 
site shoulder,  under  the  affected 
mamma,  and  through  the  axilla  of 
the  same  side ;  from  this  point  con- 
duct the  roller  transversely  around 
the  chest,  covering  the  lowest  por- 
tion of  the  gland  in  its  course.  Con- 
tinue making  oblique  turns  of  the 
shoulder  and  axilla,  alternating  with 
circular  turns  of  the  chest,  each  of 
the  respective  turns  overlapping  the 
upper  part  of  the  preceding  by  about  one-third,  till  the  aflected  breast  is 
completely  covered  by  oblique  and  circular  turns.    (Fig.  61.) 


Posterior  figure-of-eight  bandage  of  the  chest. 


Fig.  61. 


Fig.  62. 


Suspensory  and  compressor  bandage  of  tho  breast. 


Suspensory  and  compressor  bandage  of  both  breasts. 


BANDAGES   TOR    THE    HEAD. 


493 


Fig.  63. 


The  Suspensory  and  Compressor  of  both  Breasts. — Two  rollers,  each  6|-7f 
centimetres  (2J-3  inches)  wide  and  6|  metres  (7  yards)  long.  Secure  the 
initial  end  by  two  oblique  turns  of  the  shoulder  and  the  axilla,  as  in  the  pre- 
ceding bandage ;  then  carry  the  roller  transversely  across  the  back,  up  under 
the  breast  and  over  the  shoulder,  thence  obliquely  downwards  over  the  back 
and  towards  the  other  side,  and  transversely  around  the  front  of  the  chest 
(covering  the  lower  part  of  both  breasts)  to  the  point  of  beginning  on  the 
back.  Continue  the  application  of  the  roller  first  by  an  oblique  turn  of  one 
shoulder  and  the  opposite  axilla,  then  of  the  other  axilla  and  the  opposite  shoul- 
der, followed  by  a  circular  turn  of  the  front  of  the  thorax.  Each  turn,  both 
of  the  oblique  and  of  the  circular  series,  should  overlap  one-third  of  the  pre- 
ceding in  an  ascending  order,  till  both  breasts  are  covered  by  oblique  and 
circular  turns.    (Fig.  62.) 

VelpeaiCs  Bandage. — Two  rollers,  each  6  J  centimetres  (2|  inches)  wide  and 
65-  metres  (7  yards)  long.  Let  the  patient  place  the  hand  of  the  affected  side 
on  the  opposite  shoulder,  then  apply  the  initial  end  of  a  roller  on  the  body  of 
the  scapula  of  the  sound  side,  and  secure  it  by 
two  turns  made  by  conducting  the  roller  over 
the  shoulder  of  the  affected  side,  down  the  outer 
and  posterior  surface  of  the  arm  of  the  same 
side,  behind  the  point  of  the  elbow,  thence  ob- 
liquely across  the  front  of  the  chest  and  through 
the  axilla  of  the  sound  side  to  the  point  of  be- 
ginning. .  From  this  point,  cany  the  roller  in 
a  transverse  direction  around  the  thorax,  pass- 
ing over  the  flexed  elbow  of  the  affected  side, 
thence  through  the  axilla  to  the  back.  Carry 
the  roller  again  over  the  shoulder,  down  the 
outer  and  posterior  surface  of  the  arm,  behind 
the  elbow,  obliquely  across  the  front  of  the 
chest,  through  the  axilla  of  the  sound  side, 
and  thence  around  the  chest  and  arm.  The 
application  of  the  oblique  and  circular  turns 
is  continued  in  like  manner  till  the  flexed 
arm  is  firmly  bound  to  the  anterior  surface  of 
the  chest.  The  turns  running  over  the  shoul- 
der and  winding  round  the  outer  and  posterior 
surface  of  the  arm,  should  advance  towards 
the  point  of  the  elbow  by  each  overlapping 
tiro-thirds  of  the  preceding  turn;  the, circular 
turns  should  ascend  the  arm  and  chest  from  the 
point  of  the  elbow  by  each  covering  one-third 
of  the  preceding  turn.    (Fig.  63.) 


Velpeau's  bandage. 


Bandages  for  the  Head. —  Tlie  Figure-of-eight  Bandage  of  the  Head  and  Jaw. 
— This  bandage  is  commonly  called  Barton's  bandage.  A  roller  5  centime!  res 
(2  inches)  wide  and  4|  metres  (5  yards)  long.  When  this  bandage  is  used  for 
fracture  of  the  lower  jaw,  its  initial  extremity  is  placed  on  the  "head  just  be- 
hind the  mastoid  process  of  the  sound  side,  and  is  carried  under  the  occipital 
protuberance,  obliquely  upwards,  under  and  in  front  of  the  parietal  eminence, 
across  the  vertex,  down  the  side  of  the  face  on  the  sound  side,  beneath  the 
jaw,  thence  up  along  the  side  of  the  face,  over  the  top  of  the  head  (passing 
over  the  other  turn  in  the  median  line),  under  the  parietal  eminence  to  the 
point  of  commencement.     It  is  then  conducted  under  the  occipital  protuber- 


494 


MINOR   SURGERY. 


ance,  forward  under  the  ear  and  in  front  of  the  chin,  and  thence  back  to  the 
point  from  which  the  roller  started.  Continue  to  make  the  figure-of-eight 
turns  over  the  head  and  the  circular  turns  around  the  base  of  the  skull  till  the 
bandage  is  exhausted.  Each  turn  should  completely  cover  the  preceding,  so 
that  the  bandage  when  applied  should  look  as  if  it  were  formed  of  single 
turns.  In  order  that  the  bandage  may  not  be  easily  displaced,  the  different 
intersections  should  be  pinned.    (Fig.  64.) 

Fig.  64. 


Crossed  or  oblique  bandage  of  the  angle  of  the  jaw. 


The    Crossed  or    Oblique  Bandage  of  the 
Angle  of  the  Jaw. — A  roller  5  centimetres 
(2  inches)  wide  and  4|  metres  (5  yards)  long. 
Barton's  bandage.  Make  fast  the  initial  end  of  the  bandage  by 

two  circular  turns  around  the  vault  of  the 
cranium,  going  from  left  to  right,  if  it  is  designed  to  cover  the  left  angle  of 
the  lower  jaw,  and  vice  versa  if  the  right  angle.  On  reaching  the  back  of 
the  head,  conduct  the  bandage  obliquely  across  the  nape  of  the  neck,  under 
the  ear  and  the  jaw  on  the  sound  side  to  the  angle  on  the  affected  side,  thence 
up  over  the  face  in  a  line  half  way  between  the  eye  and  the  ear,  obliquely 
across  the  top  of  the  head,  and  down  behind  the  ear  of  the  sound  side  ;  from 
this  point  carry  the  bandage  again  under  the  jaw  and  up  over  the  side  of  the 
face,  making  it  overlap  the  posterior  two-thirds  of  the  preceding  turn,  thence 
obliquely  across  the  top  of  the  head,  down  behind  the  ear  of  the  sound  side, 
and  again  under  the  jaw  and  up  over  the  face,  coveritig  the  posterior  two- 
thirds  of  the  second  upward  turn.  When  the  intersection  of  the  circular  and 
the  descending  turns  is  reached  on  the  sound  side,  reverse  the  bandage  and 
terminate  it  by  two  circular  turns  around  the  head.    (Fig.  65.) 

This  bandage  will  be  found  useful  for  retaining  dressings  on  the  side  of  the 
face  in  cases  of  wounds  of  the  parotid  region.  "When  employed  in  the  treat- 
ment of  fracture  of  the  ramus  and  neck  of  the  lower  jaw,  an  oblong  compress 
should  be  placed  between  the  seat  of  fracture  and  the  ascending  turns  of  the 
bandage. 
/ 
The  Recurrent  Bandage  of  the  I  had. — A  roller  5  centimetres  (2  inches)  wide 
and  4.1  metres  (5  yards)  long.  Secure  the  initial  extremity  of  the  roller  by 
two  circular  turns  around  the  forehead  and  occiput;  on  reaching  the  middle 
of  the  forehead  or  the  occipital  protuberance,  reverse  the  roller  and  carry  it 
over  the  top  of  the  head  to  a  poinl  directly  opposite,  where  it  is  again  reversed 
or  turned  back,  and  conducted  back  over  the  vertex  to  the  point  of  commence- 


BANDAGES  FOR  THE  HEAD. 


495 


ment,  overlapping  one-third  or  one-half  of  the  preceding  turn.  These  recur- 
rent turns  over  the  summit  of  the  skull  are  repeated  till  the  top  of  the  head 
is  entirely  covered,  after  which  the  bandage  is  reversed  and  two  circular 
turns  are  made  around  the  vault  of  the  cranium,  to  secure  the  ends  of  the 
recurrent  turns  just  above  the  root  of  the  nose  and  below  the  occipital  protu- 
berance. (Fig.  66.)  While  this  bandage  is  being  applied,  one  extremity 
of  the  recurrent  turn  must  be  kept  in  position  either  by  an  assistant  or  by  the 
patient ;  the  other  extremity  may  be  retained  by  the  surgeon  himself,  till 
they  are  made  fast  by  the  terminal  circular  turns. 


Fis-  66. 


Fig.  67. 


Recurrent  bandage  of  the  head. 


V-bandage  of  the  head. 


Tlie  V-bandage  of  the  Head. — A  roller  5  centimetres  (2  inches)  wide  and 
3f  metres  (4  yards)  long.  Secure  the  initial  extremity  of  the  roller  by  two 
circular  turns  around  the  vault  of  the  cranium,  and,  on  arriving  at  the  back 
of  the  head,  conduct  the  roller  forward  under  the  ear,  over  the  upper  or  lower 
lip,  as  the  case  may  be,  and  backward  on  the  opposite  side  of  the  head  to  the 
occipital  protuberance.  Then  make  alternate  turns  around  the  base  of  the 
cranium  and  the  front  of  the  face,  and  terminate  the  bandage  by  pinning  it 
at  the  intersection  of  the  turns  on  the  occiput.  (Fig.  67.)  This  bandage  was 
suggested  by  the  writer  for  the  purpose  of  retaining 
dressings  on  the  lip  or  the  front  of  the  chin,  in  cases  Fig.  68. 

of  wound  of  those  parts.  In  consequence  of  the 
direction  of  its  turns,  this  bandage  offers  no  obstruc- 
tion to  the  patient  opening  his  mouth,  which  is  not 
the  case  with  Barton's  bandage  when  it  is  used  to 
meet  the  same  indications. 

Other  Roller  Bandages. —  Tlie  Recurrent  Band- 
age for  Stumps  after  Amputation. — A  roller  5-6| 
centimetres  (2-2 J  inches)  wide  and  4J-6J  metres 
(5-7  yards)  long.  After  securing  the  initial  end  of 
the  roller  by  two  circular  turns  around  the  stump, 
a  few  inches  above  its  extremity,  reverse  the  band- 
age on  the  under  or  posterior  surface  of  the  stump, 
and  conduct  it  over  the  extremity  to  a  point  oppo- 
site, on  the  upper  aspect,  thence  back  over  the  end 
of  the  stump  to  the  point  of  beginning.  Repeat 
these  recurrent  turns,  each  turn  overlapping  the  preceding  by  one-third  or 


Recurrent  bandage  for  stumps. 


496  MINOR   SURGERY. 

one-half  of  its  width,  covering  first  one  half  of  the  end  of  the  stump  and 
then  the  other,  after  which  make  two  circular  turns,  to  fix  the  extremities  of 
the  recurrent  turns.  If  considered  necessary,  the  stump  may  now  be  envel- 
oped by  spiral  or  spiral  reversed  turns  made  in  the  usual  way.    (Fig.  68.) 

In  addition  to  the  foregoing  roller  bandages,  another  variety,  denominated 
the  T-bandage,  is  occasionally  used  to  retain  dressings.  The  simplest  form  of 
the  T-bandage  consists  of  two  strips  of  muslin,  one  a  transverse  piece,  suffi- 
ciently long  to  pass  once  or  twice  around  the  part  to  which  it  is  to  be  applied ; 
the  other,  a  longitudinal  piece,  which  is  sewed  at  right  angles  to,  and  at  the 
middle  of,  the  transverse  piece.  The  longitudinal  piece  should  be,  as  a  rule, 
about  half  the  length  of  the  other.  When  two  longitudinal  strips  are  attached 
to  the  transverse  piece,  the  double  T-bandage  is  formed. 

The  Single  T-bandage  is  sometimes  applied  to  the  head,  to  keep  dressings  on 
the  scalp.  In  applying  it  to  this  portion  of  the  body,  the  transverse  piece  is 
carried  around  the  vault  of  the  cranium,  and  the  longitudinal  strip  taken 
over  the  summit  of  the  head  and  beneath  the  transverse  strip  on  the  opposite 
side;  it  is  then  turned  back  on  itself  and  pinned.  When  it  is  necessary  to 
cover  a  considerable  surface  of  the  scalp,  the  longitudinal  piece  may  be  made 
of  sufficient  width  to  meet  the  particular  indication.  If  the  free  end  of  the 
longitudinal  piece  be  slit  into  two  tails  for  about  two-thirds  of  its  length,  the 
single  T-bandage  becomes  a  useful  means  of  keeping  dressings  on  the  perineum 
after  operation,  as  in  eases  of  fistula  and  abscess  in  this  region.  When  this 
form  of  T-bandage  is  applied  to  the  perineum,  the  transverse  piece  is  secured 
around  the  body,  just  above  the  pelvis,  while  the  longitudinal  piece  is  brought 
down  between  the  nates,  and  its  tails,  separated  so  as  to  pass  on  either  side  of 
the  genitals,  are  carried  obliquely  upwards  and  outwards  and  fastened  to  the 
transverse  piece.  Another  modification  of  the  single  T-bandage  is  employed 
for  the  ear.  The  modification  consists  in  attaching  one  end  of  an  ear-shaped 
piece  of  muslin  to  the  centre  of  a  transverse  strip ;  to  the  other  extremity  of 
the  ear-shaped  piece  is  sewed  a  longitudinal  strip.  If  it  is  designed  to  retain 
a  dressing  on  the  surface  of  the  head  immediately  around  the  ear,  a  slit  is 
made  in  the  ear-shaped  piece,  through  which  the  auricle  passes. 

The  Double  T-bandage  is  a  convenient  means  of  retaining  a  dressing  on  the 
nose.  In  its  application,  the  portion  of  the  transverse  strip  intervening  between 
the  attachments  of  the  longitudinal  pieces,  is  placed  on  the  upper  lip  below 
the  nose ;  the  longitudinal  pieces  are  then  brought  up  along  the  sides  of  the 
nose  to  its  root,  where  they  cross  each  other ;  thence  they  pass  over  the  top 
of  the  head,  and  are  secured  by  the  extremities  of  the  transverse  strips  which 
are  carried  around  the  head.  The  double  T-bandage  consisting  of  a  broad 
transverse  piece  of  muslin  with  two  narrow  longitudinal  strips  sewed  to  its 
upper  border,  is  the  best  bandage  in  use  for  retaining  dressings  on  the  chest, 
especially  after  operations  on  the  mamma.  The  transverse  piece  should  be 
about  20|  centimetres  (8  inches)  wide,  and  long  enough  to  pass  one  and  a 
quarter  times  around  the  thorax.  The  two  longitudinal  strips,  each  about  5 
centimetres  (2  inches)  wide  and  51  centimetres  (20  inches)  long,  should  be 
attached  to  the  transverse  piece,  a  short  distance  apart,  one  on  either  side  of 
its  middle.  The  transverse  piece  is  carried  around  the  chest  and  pinned  in 
tit  nit ;  the  longitudinal  strips  arc  brought  directly  over  the  shoulders,  and  se- 
cured by  pins  to  the  upper  margin  of  the  broad  piece. 

Another  form  of  bandage,  termed  the  Sling,  is  occasionally  found  serviceable 
in  cases  of  fracture  of  the  lower  jaw,  and  in  keeping  dressings  on  the  nape  of 


HANDKERCHIEF  BANDAGES. 


497 


the  neck,  the  chin,  or  other  parts  of  the  body.  To  make  a  sling,  or  four- 
tailed  bandage,  take  a  piece  of  broad  bandage,  long  enough  to  encircle  the  part 
to  which  it  is  to  be  applied  and  to  overlap  a  little,  and  split  both  ends  to- 
wards the  centre.  The  central  portion  of  the  piece  thus  treated  is  called  the 
body ;  the  extremities  the  tails.  To  apply  the  four-tailed  bandage  to  the  nape 
of  the  neck,  place  the  body  directly  over  the  dressing  which  it  is  designed  to 
retain,  and  carry  the  upper  tails  around  the  forehead  and  the  lower  tails  around 
the  neck,  where  they  may  be  secured  by  pins.  A  similar  bandage  may  be 
used  as  a  temporary  support  in  cases  of  fracture  of  the  lower  jaw.  The  body 
of  the  bandage  is  placed  beneath  the  chin,  and  the  upper  tails  are  directed 
backward  below  the  ears,  towards  the  occiput ;  before  securing  these,  the 
lower  tails  are  carried  up  the  sides  of  the  face,  crossed  on  the  vertex  and  se- 
cured by  pins  where  they  terminate.  The  lower  tails  are  then  crossed  below 
the  occipital  protuberance,  and  brought  above  the  ears  towards  the  forehead, 
where  they  are  pinned  together. 

The  Many-tailed  Bandage,  or  the  Bandage  of  Seultetus,  is  a  convenient  dress- 
ing in  some  cases  of  compound  fracture  or  severe  wounds ;  for,  after  it  has 
been  once  applied,  it  can  be  renewed  without  disturbing  the  affected  part.  It 
is  made  by  cutting  a  roller 

bandage   into  the  requisite  Fis-  69- 

number  of  pieces,  each  long 
enough  to  go  around  the 
part  and  overlap  5-7|  centi- 
metres (2-3  inches).  These 
pieces  are  disposed  in  such  a 
way,  under  the  part,  that 
the  first  piece  shall  be  over- 
lapped by  the  second,  the 
second  by  the  third,  and  so 
on,  from  below  upwards ;  the 
extremities  of  the  last  piece 
are  secured  by  pins.  (Fig. 
69.)  Whenever  it  is  necessary  to  change  strips  that  have  become  soiled,  it 
can  be  readily  done,  without  raising  the  limb,  by  pinning  fresh  pieces  of 
bandage  to  those  which  are  soiled,  when,  as  the  latter  are  pulled  out,  the 
former  are  drawn  beneath  the  limb.  This  bandage  is  sometimes  made  by 
sewing  a  longitudinal  piece  to  the  middle  of  the  several  strips ;  this  arrange- 
ment, however,  is  objectionable,  as  it  prevents  single  strips  from  being  removed 
when  they  have  become  soiled. 

Handkerchief  Bandages. — Handkerchiefs  or  square  pieces  of  muslin  may 
be  resorted  to  with  advantage,  in  many  cases,  as  provisional,  or  even  as  perma- 
nent dressings.  M.  Mayor,  a  Swiss  surgeon,  reduced  the  application  of  hand- 
kerchief dressings  to  a  system,  nearly  fifty  years  ago,  whence  these  bandages 
are  generally  called  "  Mayor's  handkerchiefs."  The  various  handkerchief 
bandages  are  all  modifications  of  the  simple  handkerchief,  or  square  piece  of 
muslin.  The  different  forms  that  the  handkerchief  is  made  to  assume  are 
(1)  The  Oblong,  made  by  simply  folding  the  square  once  on  itself;  (2)  the 
Triangle,  made  by  bringing  together  the  diagonal  angles  of  a  square,  the 
parts  of  the  triangle  being  the  base,  the  apex  or  summit,  and  the  angles ;  (3) 
the  Cravat,  formed  by  folding  a  triangle  from  its  summit  towards  its  base; 
and  (4)  the  Cord,  a  cravat  twisted,  the  parts  of  the  cravat  and  the  cord  being 
the  body  and  the  extremities. 

This  system  of  provisional  dressings  has  an  elaborate  nomenclature  founded 
vol.  i.— 32 


Bandage  of  Scultetus. 


498 


MINOR   SURGERY. 


upon  the  shape  of  the  bandages  and  the  anatomical  designation  of  the  parts 
to  which  they  are  to  be  applied.  The  essential  point  to  be  borne  in  mind  in 
the  application  of  these  dressings,  is  that  the  base  of  the  triangle,  or  the  body 
of  the  cravat,  is  to  be  placed  on  the  part,  the  designation  of  which  forms  the 
first  portion  of  the  name  of  the  bandage.  The  angles  or  extremities  are,  as  a 
rule,  carried  around  the  part,  and  either  knotted  or  fastened  with  pins.  The 
advantage  of  this  arrangement  of  the  names  may  be  illustrated  in  the  case  of 
the  Occipito-Frontal  Triangle,  or  the  Fronto-Occipito-Labial  Cravat.  The 
name  of  the  former  indicates  that  a  handkerchief,  in  the  shape  of  a  tri- 
angle, is  to  be  used,  and  that  its  base  is  to  be  applied  to  the  occiput,  and  its 
angles  carried  around  the  head  to  the  frontal  region  ;  that  of  the  latter  denotes 
that  a  handkerchief  folded  in  cravat  form  is  to  be  employed,  its  body  being 
placed  on  the  forehead,  and  its  extremities  crossed  on  the  occipital  region 
and  terminated  on  the  upper  or  loAver  lip,  as  the  case  may  be. 

Fixed  Dressings,  or  Hardening  Bandages. — A  great  variety  of  substances 
are  used,  at  the  present  time,  to  give  greater  fixity  and  solidity  to  bandages,  in 
the  treatment  of  fractures  and  other  surgical  affections.  The  substances  most 
commonly  employed  in  the  preparation  of  fixed  dressings  are  plaster  of  Paris, 
or  gypsum,  starch,  and  silicate  of  potassium ;  other  materials  are  sometimes 
used,  among  which  may  be  mentioned  a  mixture  of  chalk  and  gum,  a  combi- 
nation of  oxide  of  zinc  and  glue,  glue  alone,  and  paraffine. 

Plaster  of  Paris  Bandage. — The  plaster  for  this  purpose  should  be  the  extra- 
calcined  variety  used  by  dentists  for  taking  casts  for  teeth,  and  by  modellers. 

If  it  is  not  fresh  and  free  from  moisture,  it  will  fail 
to  serve  the  purpose  for  which  it  is  used.  This  band- 
age may  be  applied  in  two  ways : — 

First  Method.  Add  dry  plaster  to  some  cold  water 
in  a  basin,  and  stir  the  mixture  till  it  becomes  of 
the  consistence  of  cream.  Thus  prepared,  the  plas- 
ter may  be  smeared  over  the  surface  of  a  bandage 
on  a  limb;  or  a  bandage  previously  wetted  may  be 
loosely  rolled  in  the  plaster-cream,  and  then  applied. 
Strips  of  bandage  dipped  in  plaster-cream  are  some- 
times applied  after  the  manner  of  the  many-tailed 
bandage  of  Scultetus.  To  render  the  surface  of  the 
dressing  smooth  after  it  has  been  applied  in  either 
of  the  above  ways,  a  little  dry  plaster  may  be  rubbed 
over  it. 

Secovd  Method.  The  bandages  used  in  this  method 
are  made  of  some  loosely-woven  material,  such  as 
cross-barred  muslin,  mosquito-netting,  or  (what  is 
far  belter  than  either)  crinoline,  a  substance  recom- 
mended by  Prof.  Say  re.  This  material  is  cut  into 
strips  <^.-7f  centimetres  (2|-3  inches)  wide  and 
4!-(!|  metres  (5-7  yards)  long.  As  these  strips  are 
loosely  rolled  into  cylinders,  dry  plaster  is  rubbed 
into  their  meshes,  either  by  hand  or  by  means  of  a 
machine  called  axplaster  bandage  winder  (Fig.  70). 
Bandages  thus  prepared  may  be  kept  ready  for  use 
in  some  air-tight  receptacle.  Before  applying  one 
of  these  bandages,  il  is  placed  on  end  in  a  basin  of 
tepid  water,  sufficiently  deep  to  cover  it  entirely, 

Apparatus  l^r  u  iinlitig  plaster  ',    .        <■<■  -,    ,  •       i-n    j_i       i      i  1  i  j?      • 

bandages.  and  is  allowed  to  remain  till  the  bubbles  of  air  cease 


FIXED    BANDAGES. 


499 


to  escape  through  the  water  from  the  upper  end  of  the  roller ;  it  is  then  taken 
out  of  the  water  and  firmly  squeezed  between  the  hands,  to  remove  the  ex<  vss 
•of  liquid,  when  it  is  ready  for  application.  When  two  or  more  bandages  are 
to  be  used,  a  dry  bandage  should  always  be  put  in  the  water  before  the  satu- 
rated one  is  taken  out;  if  this  be  done,  there  will  be  no  unnecessary  delay  in 
the  application  of  the  dressing.  As  a  roller  is  applied,  the  surface  of  the  turns 
should  be  gently  smoothed  by  the  operator  or  by  an  assistant,  in  order  that 
the  plaster  may  be  uniformly  spread  over  the  surface  of  the  dressing.  Three 
or  four  thicknesses  of  bandage  are  usually  sufficient. 

Plaster  bandages  should  never  be  applied  directly  upon  the  skin.  The  best 
protective  for  an  extremity  is  a  flannel  roller,  or  a  light  woollen  stocking;  for 
the  trunk,  a  closelj'  fitting  knitted  shirt  or  vest.  If  bandages  with  dry 
plaster  well  rubbed  into  their  meshes  are  evenly  applied  to  a  part  after  being 
thoroughly  saturated  with  water,  there  will  be  no  need  of  smearing  the 
successive  layers,  or  the  outer  surface  of  the  dressing,  with  plaster  cream. 
Under  favorable  circumstances,  a  plaster  bandage  becomes  perfectly  firm  in 
from  fifteen  to  thirty  minutes,  and,  unlike  the  other  fixed  dressings,  it 
expands  a  little  as  it  hardens.  A  small  quantity  of  size,  or  stale  beer,  put  in 
the  water,  will  retard  the  setting  of  plaster;  on  the  other  hand,  the  addition 
of  a  little  salt  will  hasten  it. 

The  removal  of  a  plaster  bandage,  as  well  as  other  fixed  dressings,  may  be 
accomplished  by  slitting  it  up  with  a  stout-bladed  knife,  or  with  Seutin's 
or  Von  Bruns's  pliers.  (Figs.  71,  72.)       The  writer  has  recently  had  made 


Seutin's  pliers. 

Fig.  72. 


Von  Bruns's  pliers. 


a  plaster-bandage  saw,  of  the  shape  represented  in  Fig.  73,    which  greatly 
facilitates  the  division  of  these  bandages.     It  is  necessary  that  the  teeth 


Fig.  73. 


Saw  for  removing'  plaster-of-Paris  bandages. 


should  be  widely  set,  so  that  a  wide  groove  may  be  cut  in  the  bandage  for 
the  free  passage  of  the  saw. 


500  MINOR    SURGERY. 

Starched  Bandage. — The  starch  is  first  mixed  with  enough  cold  water  to 
make  it  of  the  consistence  of  cream ;  then,  as  the  mixture  is  stirred,  boiling 
water  is  gradually  added  to  it  till  it  becomes  a  clear,  thickish  mucilage, 
which  is  known  as  "  clear-starch."  The  starch  mucilage  is  painted  with  a 
brush,  or  smeared  with  the  hand,  over  the  outer  surface  of  the  bandages  as 
they  are  applied  to  a  limb.  To  give  additional  support,  pieces  of  paste- 
board cut  or  torn  of  the  requisite  size  and  shape,  and  thoroughly  soaked  in 
starch,  are  sometimes  placed  between  the  layers  of  bandage.  In  order  that 
there  may  be  no  liability  to  dangerous  constriction  of  a  part,  only  those 
bandages  that  have  been  washed  and  well  shrunk  should  be  used  with 
starch.  The  starched  bandage  dries  very  slowly,  requiring  from  twenty-four 
to  forty-eight  hours  before  it  becomes  firm. 

Gum  and  Chalk  Bandage. — For  this  bandage,  a  mixture  of  the  two  sub- 
stances is  made  by  adding  to  equal  parts  of  powdered  gum  arabic  and  pre- 
cipitated chalk,  enough  boiling  water  to  bring  the  mass  to  the  consistence  of 
cream.  This  dressing  is  applied  in  the  same  manner  as  the  preceding;  it 
requires  only  five  or  six  hours  to  harden,  and  hence  is  to  be  preferred  to  the 
starched  bandage. 

Silicate  of  Potassium  Bandage. — "When  silicate  of  potassium  (liquid  glass) 
is  employed  to  stiffen  bandages,  it  is  painted  over  the  several  layers  of 
bandage  with  a  broad  brush.  It  takes  about  the  same  length  of  time  to 
become  firm  as  the  starched  bandage,  and,  unless  washed  bandages  are 
employed,  its  use  is  attended  with  the  same  dangerous  liability  to  strangu- 
lation of  the  limb.  In  consequence  of  the  ready  solubility  of  silicate  of 
potassium,  the  bandage  may  be  easily  cut  up  with  scissors  after  it  has  been 
softened  by  the  use  of  warm  water. 

Paraffine  Bandage. — One  disadvantage  attributed  to  the  foregoing  fixed 
dressings  is  their  liability  to  become  offensive  from  the  absorption  of  dis- 
charges, especially  in  cases  of  compound  fracture.  Mr.  Lawson  Tait  claims 
that  paraffine,  in  consequence  of  its  non-absorbent  property,  is  not  open  to 
this  objection.  Paraffine,  which  melts  at  from  105°  to  120°  F.,  is  kept  in  a 
liquid  state  by  being  placed  in  a  bowl  floating  in  hot  water ;  it  may  be  most 
conveniently  applied  by  passing  through  it  flannel  bandages  of  loose  texture, 
as  they  are  being  placed  upon  a  limb.  In  the  course  of  five  or  ten  minutes, 
the  bandage  will  become  firm,  and,  if  it  be  deemed  necessary,  the  dressing 
may  be  strengthened  by  brushing  over  it  melted  paraffine.  Should  the 
coating  of  paraffine  crack,  the  damage  may  be  easily  repaired  with  a  hot 
wire. 

Glue  alone,  as  used  by  the  late  Mr.  C.  De  Morgan,  or  in  combination  with 
oxide  of  zinc,  as  suggested  by  Dr.  Levis,  may  be  employed  to  make  fixed 
dressings.  It  does  not  possess  any  decided  advantages  over  the  materials 
already  noted,  to  compensate  in  any  way  for  the  increased  trouble  which 
attends  its  application. 


Revulsion  and  Counter-Irritation. 

It  has  been  demonstrated  by  experience  of  the  most  positive  character, 
that  artificial  irritations,  under  favorable  circumstances,  have  a  decided 
effect  in  modifying  a  great  variety  of  morbid  processes.  The  substances 
employed  to  excite  external  irritation  are  termed  counter-irritants ;  and  the 


REVULSION    AND    COUNTER-IRRITATION.  501 

extent  of  their  action  varies  from  the  production  of  superficial  redness  to  the 
complete  destruction  of  the  vitality  of  the  part  to  which  they  are  applied. 

Rubefacients. — These  agents,  in  consequence  of  their  irritating  properties, 
excite,  when  applied  to  the  surface  of  the  body,  intense  redness  and  con- 
gestion of  the  skin,  which  are  of  temporary  duration  only.  "When  it  is 
desirable  to  make  a  quick  impression  on  the  skin,  flannel  cloths  wrung  out 
of  hot  water  and  laid  upon  the  part,  will  answer  the  purpose  if  they  are 
frequently  renewed. 

Oil  of  turpentine  is  not  unfrequently  used  as  a  counter-irritant,  in  the  form 
of  stupes.  These  are  made  either  by  sprinkling  the  oil  of  turpentine  over 
flannel  cloths  that  have  been  wrung  out  of  hot  water,  or  by  dipping  these 
hot  cloths  into  warm  turpentine  ;  in  either  case  the  excess  of  turpentine 
should  be  squeezed  out  of  the  stupes  before  they  are  applied.  A  turpentine 
stupe  ought  not  to  be  left  on  longer  than  twenty  minutes. 

A  few  drops  of  chloroform,  on  a  piece  of  flannel  or  folded  napkin,  confined 
to  the  skin  by  oiled  silk,  will  quickly  excite  a  rubefacient  effect. 

Mustard-flour  is  probably  more  often  employed  as  a  rubefacient  than  any 
other  substance.  Of  the  two  varieties  of  mustard,  Sinapis  alba  and  Sinapia 
nigra,  the  latter  is  the  more  powerful — a  fact  that  ought  not  to  be  lost  sight 
of  in  the  use  of  these  substances  as  revulsives.  The  advantage  attending  the 
use  of  this  material  is  the  ease  with  which  its  specific  action  may  be  regu- 
lated. The  usual  method  of  preparing  a  sinapism  is  to  mix  the  mustard-flour 
with  warm  water,  and  spread  the  paste  on  muslin  or  paper.  The  surface  of 
the  sinapism  should  be  covered  with  some  thin  material,  such  as  gauze,  to 
prevent  any  of  the  mustard  from  sticking  to  the  skin  when  the  application 
is  removed.  The  intensity  of  the  irritating  effect  of  mustard  may  be  dimin- 
ished by  diluting  the  mustard-flour  with  wheat-flour,  Indian-meal,  or  linseed- 
meal  ;  the  usual  proportions  are,  for  the  black  variety  about  one-half,  for  the 
white  one-third.  A  sinapism  of  this  strength  may  be  allowed  to  remain  for 
a  period  varying  from  fifteen  to  thirty  minutes,  according  to  the  texture  of 
the  skin  and  the  sensations  of  the  patient ;  its  action  should  never  be  allowed 
to  extend  to  vesication,  for  a  blister  produced  by  mustard  is  excessively  painful, 
and  slow  in  healing.  After  the  removal  of  a  mustard  poultice,  the  irritated 
surface  of  the  skin  should  be  protected  by  a  piece  of  lint  smeared  with  oxide 
of  zinc  ointment  or  Goulard's  cerate.  A  mustai^d  foot-bath,  made  by  putting 
a  tablespoonful  or  two  of  mustard-flour  into  a  bucket  or  foot-tub  of  water  at 
a  temperature  of  105°  F.,  is  an  efficient  method  of  quickly  exciting  revul- 
sive action.  In  the  employment  of  counter-irritants  with  patients  who  are 
in  a  comatose  state,  or  deeply  under  the  influence  of  a  narcotic,  care  must  be 
observed  that  the  applications  are  not  too  long  continued,  lest  troublesome 
consequences  should  arise  as  a  result  of  the  impaired  vitality  of  the  tissues,  or 
of  a  temporary  loss  of  the  sensation  of  the  patient. 

Vesicants. — These  substances  are  employed  when  it  is  desirable  to  make 
a  more  decided  and  permanent  counter-irritant  effect  than  that  produced  by 
the  use  of  rubefacients.  By  their  specific  action  on  the  skin,  they  cause  an 
effusion  of  serum,  or  of  serum  and  lymph,  beneath  the  cuticle,  giving  rise  to 
vesicles  or  blisters.  When  there  are  indications  for  rapid  vesication,  it  may 
be  produced  by  the  application  of  the  aqua  ammonice  fortior,  or  of  chloroform 
confined  to  the  surface  of  the  body  by  an  inverted  watch-glass;  or  by  the 
employment  of  iron  heated  in  boiling  water.  The  substance  most  commonly 
resorted  to  for  producing  vesication,  is  cantharis,  or  Spanish  fly,  which  may  be 
used  in  the  form  of  a  cerate,  or  in  combination  with  collodion.  There  is  still 
another  form,  the  cantharides  paper  (charta  carttharidis),  which  is  considered 


502  MINOR   SURGERY. 

by  some  more  elegant  than  either  of  the  above  preparations,  and  nearly  as 
efficient.  The  most  convenient  way  of  using  the  ceratum  cantharidis  is  to 
spread  it  on  a  piece  of  adhesive  or  diachylon  plaster,  leaving  a  margin  of 
about  1 J-2  centimetres  (J  to  f  of  an  inch)  wide,  uncovered,  which  will  adhere 
to  the  skin  and  thus  hold  the  blister  in  position.  The  average  length  of  time 
that  a  fly-blister  may  be  allowed  to  remain  in  contact  with  the  skin,  is  from 
six  to  eight  hours ;  then  it  should  be  removed,  and  the  part  covered  with  a 
flaxseed-meal  poultice.  A  blister  raised  in  this  way  is  not  very  painful,  nor 
is  it  apt  to  be  followed  by  strangury.  In  cases  in  which  the  skin  is  delicate, 
or  in  which  urinary  irritation  is  apprehended,  camphor,  alone  or  in  combina- 
tion with  opium,  may  be  incorporated  with  the  cerate  before  it  is  applied. 
Cantharidal  collodion,  painted  on  the  skin  in  three  or  four  layers,  with  a  camel's- 
hair  brush,  is  the  best  means  of  blistering  in  cases  of  maniacs  or  other  patients 
whose  movements  are  not  easily  controlled  ;  it  is,  likewise,  a  very  convenient 
application  for  uneven  or  irregular  surfaces.  Blisters  must  be  cautiously 
used  with  children,  even  with  those  who  are  robust,  and  they  are  positively 
contra-indicated  in  the  case  of  children  suffering  from  any  low  form  of  disease. 

When  a  blistered  surface  is  to  be  healed  as  quickly  as  possible,  the  vesicle 
should  be  carefully  punctured  at  the  most  dependent  point,  to  let  the  serum 
escape,  and,  without  detaching  the  cuticle,  the  part  should  be  covered  with 
oxide  of  zinc  ointment  or  simple  cerate.  If,  on  the  other  hand,  there  is  need 
for  keeping  up  the  derivative  effect  of  a  blister,  the  cuticle  should  be  stripped 
off  and  the  denuded  surface  dressed  with  savine  cerate  or  mezereon  ointment, 
or  the  compound  resin  cerate. 

Nitrate  of  silver  is  sometimes  applied  to  the  skin  for  the  purpose  of  exciting 
counter-irritation.  A  strong  solution  of  this  salt  may  be  used  where  the  ob- 
ject is  simply  to  produce  rubefaction  ;  but,  for  the  purpose  of  exciting  vesica- 
tion, preference  should  be  given  to  the  solid  stick.  Freely  applied  to  the 
scrotum  in  this  form,  nitrate  of  silver  is  thought  by  some  surgeons  to  be  effi- 
cacious in  abating  an  acute  epididymitis. 

Acupuncture. — This  method  of  exciting  counter-irritation  is  effected  by 
thrusting  needles  deeply  into  the  subcutaneous  tissues,  where  they  are  allowed 
to  remain  for  a  variable  length  of  time.  The  needles  should  be  of  steel, 
polished,  strong,  sharp  pointed,  and  from  5  to  10  centimetres  (2  to  4  inches) 
long,  and  should  have  round  metallic  heads,  or  be  fixed  in  cylindrical  handles. 
In  introducing  the  needles,  the  skin  should  be  made  tense  between  the  thumb 
and  fingers  of  the  left  hand,  while  each  needle  is  forced  through  the  integument 
into  the  deep-seated  structures  by  a  rotatory  motion.  As  it  is  withdrawn, 
the  skin  around  each  needleought  to  be  supported.  In  performing  the  ope- 
ra lion  of  acupuncture,  certain  localities  containing  important  organs,  such  as 
large  bloodvessels,  the  viscera,  joints,  etc.,  must  be  avoided.  Acupunctura- 
tion  has  been  found  of  service  in  cases  of  deep-seated  neuralgia,  especially  of 
the  sciatic  nerve,  cases  of  muscular  rigidity,  obstinate  rheumatic  affections,  etc. 

Issues  are  ulcers  made  artificially  by  the  application  of  caustics,  or  the 
moxa,  or  by  the  use  of  the  knife,  for  the  purpose  of  relieving  either  local  or 
general  disease  by  establishing  a  permanent,  derivative  action.  When  they 
are  established  with  a  view  <>{'  producing  a  drain  on  the  system,  certain  situa- 
tions, such  as  the  nape  of  the  neck,  the  insertion  of  the  deltoid  muscle  on  the 
outer  side  of  the  arm,  and  the  outer  aspect  of  the  thigh,  should  be  selected; 
for  in  these  localities  the  subcutaneous  areolar  tissue  is  abundant,  and  there 
arc  no  important  bloodvessels  or  nerves.  In  the  case  of  local  affections,  cir- 
cumstances will  determine  the  points  at  which  issues  are  to  be  made.  Salient 
points  of  the  skeleton  and  the  immediate  vicinity  of  large  bloodvessels  and 


REVULSION   AND   COUNTER-IRRITATION.  503 

nerves  should,  however,  always  be  avoided.  The  plan  usually  practised  in 
making  an  issue,  is  to  protect  the  surrounding  skin  by  covering  it  with  a 
piece  of  adhesive  or  diachylon  plaster,  in  which  a  bole  is  cut  a  little  smaller 
than  the  proposed  eschar.  A  ring  of  wax  may  be  used  instead  of  plaster.  A 
small  piece  of  caustic  potassa,  or  Vienna  caustic  made  into  a  paste  by  mixing 
it  with  a  little  alcohol,  is  placed  in  the  hole,  and  kept  in  position  by  another 
strip  of  plaster.  In  an  hour  or  two,  the  strips  of  plaster  should  be  removed, 
and  the  part  washed  with  vinegar  and  water,  to  check  the  further  action  of 
the  caustic ;  a  poultice  of  llaxseed-meal  should  then  be  applied,  to  hasten 
the  separation  of  the  slough.  The  ulcer  remaining  after  the  removal  of  the 
eschar  may  be  kept  from  healing  by  placing  in  it  an  issue-pea  or  a  glass  bead, 
which  may  be  maintained  in  position  by  means  of  a  small  compress  of  lint 
and  a  strip  of  plaster ;  or,  if  the  issue  be  on  the  arm,  by  a  wire-gauze  armlet. 
Tlie  moxa  is  occasionally  used  to  make  an  issue,  but  its  application  is  so 
painful  that  a  local  anaesthetic  should  then  always  be  employed.  Thenioxa 
is  composed  of  some  combustible  material,  such  as  cotton,  lint,  agaric,  the 
pith  of  the  sunflower,  etc.,  rolled  into  cylindrical  or  pyramidal  shape,  and  is 
designed  to  be  burnt  in  contact  with  the  skin,  for  the  purpose  of  producing  an 
eschar.  That  the  combustion  of  the  moxa  may  be  more  rapid,  and  the  pain 
attending  its  application  less  prolonged,  it  is  customary  to  make  it  of  cotton 
or  lint  impregnated  with  nitrate  or  chlorate  of  potassium.  To  facilitate  the 
application  of  the  moxa,  a  convenient  instrument  called  the  porte-moxa,  or 
"  moxa-bearer,"  may  be  employed.     (Fig.  74.)      The  eschar  left  in  the  skin 

Fig.  74. 


Porte-moxa. 

after  the  burning  of  the  moxa,  is  somewhat  greater  in  extent  than  the  base 
of  the  latter.  The  treatment  of  the  slough  and  of  the  ulcer  is  the  same  as 
that  described  in  the  preceding  paragraph. 

Tlie  knife  may  be  resorted  to  for  establishing  an  issue,  either  by  raising  the 
integuments  and  cutting  them  from  within  outwards,  or  by  making  a  crucial 
incision,  well  down  into  the  subcutaneous  areolar  tissue.  Issues  made  in  this 
way  are  always  troublesome  to  keep  open,  and  hence  this  method  is  not  often 
practised. 

The  Seton,  which  is  simply  a  subcutaneous  issue,  or  a  sinus  with  two 
openings,  is  established  by  introducing  a  narrow  strip  of  muslin,  a  small  roll 
of  thread,  a  piece  of  lamp-wick,  or  a  strip  of  India-rubber  cloth,  through  the 
base  of  a  fold  of  the  integument.  This  may  be  accomplished  either  by  using 
a  seton-needle  (Fig.  75),  or  by  means  of  a  sharp-pointed  bistoury  and  an  eyed 


Seton-needle. 


probe.  A  seton  should  pass  deeply  into  the  superficial  fascia,  for  if  it  bo 
carried  between  the  skin  and  fascia,  the  former  will  slough  and  leave  an 
open  wound ;  in  order  to  get  free  drainage,  one  opening  should  be  a  little 
lower  than  the  other.  When  the  seton-thread  is  in  position,  its  ends  arc  to 
be  loosely  knotted,  and  it  should  not  be  disturbed  till  suppuration  is  fully 
established  in  the  wound.     After  this,  the  wound  is  to  be  dressed  every  day, 


504 


MINOR    SURGERY. 


and  the  seton-thread,  either  oiled  or  smeared  with  some  stimulating  ointment, 
if  it  he  desirable  to  increase  the  quantity  of  the  discharge,  should  be  moved 
a  little  at  each  change  of  dressing.  Setons  are  occasionally  used  to  empty 
chronic  abscesses  or  cysts ;  in  cases  of  the  latter,  and  in  those  of  hydrocele, 
the  presence  of  a  seton  in  the  sac  will  sometimes  effect  a  cure  by  exciting 
sufficient  inflammatory  action  to  cause  adhesion  of  the  walls. 

The  Actual  Cautery,  consisting  of  some  form  of  metallic  substance  brought 
to  a  high  degree  of  temperature,  constitutes  the  most  powerful  counter-irritant 
in  use.  It  is  likewise  employed  for  the  purposes  of  checking  hemorrhage  and 
destroying  diseased  growths.  The  cauteries  most  commonly  employed  are 
made  of  Iron,  and  are  fixed  in  handles  of  wood  or  other  non-conducting 
material,  and  have  their  heads  or  extremities  fashioned  in  a  variety  of  shapes, 
as  the  olive,  the  button,  the  hatchet,  etc.  (Fig.  76.)      This  variety  in  shape 

is  designed  to  meet  the  special  in- 
Fl&-  76-  dications  for  which  cauting-irons 

are  used,  and  to  suit  different 
localities.  In  an  emergency,  an 
ordinary  knitting-needle,  or  a 
poker,  or  other  piece  of  iron,  may 
be  made  to  serve  the  purpose. 
The  irons  may  be  heated  in  a 
brazier  which  usually  accompa- 
nies a  set  of  the  instruments,  or 
in  an  ordinary  tire,  or  by  the 
flame  of  a  spirit-lamp.  When 
the  actual  cautery  is  resorted  to 
for  its  revulsive  effect,  the  hatchet-shaped  iron  is  the  one  usually  selected. 
This,  heated  to  a  dull  red  heat,  should  be  quickly  drawn  over  the  skin  in 


Canting-irons  of  various  shapes. 


Fig.  77. 


A  B 

Paquelin's  tliormo-cautery. 

A,  spirit  lamp;  B,  cover  for  lamp  ;  C,  bottle  containing  benzole  ;  D,  cover  for  bottle;  E,  India-rubber  bulbs  and 

tubing;  F,  handle  for  knives ;  0,  II,  platinum  knives ;  I,  platinum  button. 


BLOODLETTING.  505 

lines  about  2|  centimetres  (one  inch)  apart,  either  parallel  to  or  crossing  one 
another.  The  intense  burning  that  follows  the  application  of  the  hot  iron 
may  be  allayed  by  placing  on  the  cauterized  part  compresses  wrung  out  of 
cold  water,  or  saturated  with  equal  parts  of  olive  oil  and  lime-water.  It  is 
not  deemed  prudent  to  apply  the  actual  cautery  to  the  skin  covering  salient 
points  of  the  skeleton,  or  immediately  overlying  important  organs.  Brace's 
gas  cautery,  which  consists  of  a  point,  disk,  or  wedge  of  platinum  heated  by 
a  name  of  gas,  has  the  advantage  over  the  ordinary  cauting-iron,  that  it  can 
be  easily  maintained  at  a  high  temperature  while  it  is  in  contact  with  moist 
tissue. 

A  very  convenient  and  efficient  form  of  thermo-cautery  has  been  recently 
introduced  by  Paquclin,  which  comprises  two  hollow  knives  (Fig.  77,  G,  H) 
and  a  hollow  button  of  platinum  (I) ;  a  metallic  handle  (F),  likewise  hollow 
and  covered  with  wood ;  a  reservoir  for  benzole  (C) ;  and  rubber  bulbs  and 
tubing  (E),  similar  to  those  used  with  the  hand  spray-apparatus.  In  pre- 
paring the  cautery  for  use,  the  platinum  extremity,  in  which  there  is  platinum 
sponge,  is  first  heated  by  the  flame  of  an  alcohol  lamp  (A) ;  it  is  then  quickly 
made  incandescent  by  passing  through  it  a  continuous  stream  of  air  saturated 
with  the  vapor  of  benzole.  By  compressing  the  rubber  bulb,  air  is  forced 
into  the  rubber  bag  surrounded  with  netting,  and  the  elasticity  of  this  causes 
a  steady  flow  of  air  through  the  reservoir  or  bottle  containing  benzole ;  the 
air  thus  charged  is  conveyed  by  the  rubber  tubing  to  the  platinum  point. 

The  use  of  the  galvanic  cautery  will  be  referred  to  on  a  subsequent  page. 


Bloodletting. 

The  operation  of  bloodletting  is  occasionally  resorted  to,  both  as  a  local  and 
as  a  general  remedial  measure.  The  methods  by  which  local  depletion  (that  is, 
from  the  capillaries)  is  effected,  are  scarification,  puncturation,  cupping,  and 
leeching.     General  bloodletting  comprises  venesection  and  arteriotomy. 

Scarification  consists  in  making  small  incisions  with  a  lancet  or  a  sharp- 
pointed  bistoury  in  the  surface  of  a  congested  or  inflamed  part.  By  means 
of  these  incisions,  the  overloaded  capillaries  are  promptly  relieved,  and  a  vent 
is  afforded  for  the  escape  of  transudation.  The  cases  in  which  this  operation 
is  most  efficacious  are,  inflammation  of  the  integuments,  engorgements  of  the 
tongue  and  tonsils,  chemosis  of  the  conjunctiva,  and  urinary  infiltration.  The 
incisions  should  be  in  parallel  rows,  and,  as  a  rule,  should  correspond  in 
direction  to  the  long  axis  of  the  part.  Their  length  and  depth,  as  well  as 
their  number,  must  be  determined  by  the  circumstances  of  each  individual 
case.  Care  must  be  taken  that  the  large  subcutaneous  veins  are  not  wounded. 
Warm  fomentations  will  increase  and  prolong  the  flow  of  blood  from  the 
small  wounds. 

Puncturation  is  an  operation  somewhat  similar  in  character  to  that  just 
described,  and  may  be  done  with  a  sharp-pointed,  narrow-bladed  bistoury. 
It  is  of  marked  service  in  cases  of  acute  epididymitis,  phlegmonous  erysipelas, 
etc.,  both  by  relieving  tension  and  by  effecting  depletion. 

Cupping. — Under  this  head  are  included  two  minor  operations,  viz.,  dry- 
cupping  and  wet  or  bloody-cupping.  The  use  of  cups  relieves  deep-seated 
inflammation  by  inviting  the  blood  to  the  surface. 

Dry-cupping  is  indicated  in  cases  of  inflammation  in  which  the  action  of  a 
derivative  is  desired  without  the  abstraction  of  blood.     In  an  emergency,  this 


506 


MINOR   SURGERY. 


may  be  accomplished  by  means  of  wineglasses  or  small  tumblers  instead  of 
cupping-glasses.  When  the  former  are  used,  the  air  in  them  may  be  quickly 
rarefied  by  burning  in  them  small  rolls  of  paper,  or  little  masses  of  cotton  wet 
with  alcohol,  or  by  the  introduction  of  the  flame  of  a  spirit  lamp  for  a  moment 
or  two.  In  using  cupping-glasses,  either  for  dry  or  wet-cupping,  the  glasses 
are  first  placed  on  the  part,  and  then  the  air  in  them  is  exhausted  by  means 
of  a  portable  air-pump  (Fig.  78) ;  the  immediate  effect  of  the  removal  of  the 
air  is  marked  congestion  of  the  integument  covered  by  the  glasses.  Cupping- 
glasses  are  easily  removed  by  opening  the  stopcock  with  which  they  are  pro- 
vided ;  or  they  may  be  tilted  to  one  side,  and  the  skin  gently  pressed  away 
from  the  edge  of  the  glass  on  the  opposite  side.  They  should  never  be 
pulled  off. 

Wet  or  bloody-cupping. — By  this  means  local  depletion  is  easily  effected, 
and  the  quantity  of  blood  abstracted  may  be  accurately  determined.  The 
instruments  required  for  this  operation  are  a  scarificator  (Fig.  79),  cupping- 
glasses,  and  a  portable  air-pump,  or  a  vulcanized  India-rubber  bulb  (Fig.   80) ; 


Fig.  78. 


Fig.  79. 


Fig.  80. 


Cupping-glass  and  porta- 
ble air-pump. 


Scarificator  for  wet-cupping. 


Cupping-glass  with  India-rubber 
bulb. 


in  place  of  the  scarificator,  any  sharp-pointed  knife  may  be  used.  As  a  pre- 
liminary to  the  performance  of  this  operation,  the  skin  should  be  sponged  with 
warm  water,  and  if  necessary  shaved.  The  cups  are  placed  on  the  surface,  to 
produce  superficial  congestion,  and  in  the  course  of  a  minute  or  two  should 
be  removed,  and  the  scarificator  immediately  applied.  As  soon  as  the  inci- 
sions are  made  by  springing  the  set  of  lancets  concealed  in  the  scarificator,  the 
cups  should  be  promptly  replaced.  When  the  cups  become  filled  with  blood, 
as  their  suction  power  is  exhausted,  they  should  be  taken  oft*  and  emptied; 
and,  if  more  blood  is  to  be  abstracted,  they  may  be  reapplied  to  the  same 
spots,  or  fresh  cups  maybe  substituted.  After  they  arc  removed,  the  part 
should  be  carefully  washed,  and  dressed  with  compresses  and  strips  of  plaster 
or  a  bandage.  In  using  the  scarificator,  the  blades  should  be  set  so  as  to  cut 
through  the  true  skin  only.  If  a  knife  housed  to  make  the  scarifications, 
the  same  cart;  must  be  exercised  not  to  encroach  upon  the  subcutaneous  areolar 
tissue;  the  incisions  should  be  parallel,  and  about  one  centimetre  (one-third 
of  an  inch)  apart.  Cupping  glasses  should  not  be  applied  in  the  immediate 
vicinity  of  inflamed  tissues,  nor  over  the  mammary  region.     Wet-cupping  is 


BLOODLETTING. 


507 


always  followed  by  scarring,  hence  wet-cups  should  never  be  put  on  the  upper 
part  of  the  chest  or  shoulders  of  women. 

Leeching  is  not  often  done  by  the  surgeon  himself;  still  its  importance  as 
a  remedial  measure  renders  a  knowledge  of  its  practical  application  of  service 
to  every  practitioner.  It  is  a  convenient  method  of  taking  blood  from  cer- 
tain localities  where  it  is  impossible  to  employ  cups.  In  this  country,  two 
varieties  of  leech  are  used,  known  respectively  as  the  American,  and  as  the 
European  or  Swedish  leech ;  the  former  variety  is  estimated  to  draw  about 
four  grammes  (one  fluidrachm)  of  blood  ;  the  latter  nearly  four  times  as  much. 
The  quantity  of  blood  abstracted  maybe  increased  by  applying  warm  fomen- 
tations to  the  leech-bites.  In  selecting  leeches,  preference  should  be  given  to 
those  which  are  active  and  healthy ;  they  should  be  taken  from  water  an 
hour  before  they  are  applied,  and  should  be  dried  in  a  soft,  dry  cloth.  The 
part  to  be  leeched  must  be  clean  and  free  from  hair.  If  the  leeches  are  slow 
in  taking  hold,  their  action  may  be  hastened  by  smearing  a  little  milk  or 
blood  on  the  skin ;  immersion  of  the  leeches  in  lukewarm  water  or  small  beer 
is  said  to  stimulate  them  to  bite  more  actively.  When  two  or  three  leeches 
only  are  to  be  applied,  they  may  be  taken  between  the  thumb  and  fingers  and 
held  with  their  buccal  extremity  to  the  part.  If  a  larger  number  be  used, 
they  may  be  conveniently  confined  to  the  surface  by  covering  them  with  an 
inverted  tumbler,  or  a  loose  mass  of  cotton.  By  means  of  a  leech-glass  or 
a  small  cone  of  stift  paper,  a  leech  may  be  kept  in  contact  with  a  particular 
part,  as  the  inner  canthus  of  the  eye,  the  gum,  the  verge  of  the  anus,  etc.,  till 
it  adheres ;  for  the  cervix  uteri  a  speculum  should  be  used.  In  cases  of  in- 
flammation, leeches  should  be  applied  to  the  parts  surrounding  the  seat  of 
disease,  and  not  directly  over  it ;  nor  should  they  be  put  on  the  eyelids  or  the 
scrotum,  for  here,  in  consequence  of  the  large  amount  of  loose  cellular  tissue 
and  the  delicate  nature  of  the  skin,  un- 
sightly ecchymoses  are  almost  sure  to 
follow.  Leeches  should  not  be  forcibly 
removed ;  when  they  show  no  dispo- 
sition to  relax  their  hold,  a  little  salt 
or  snuff  sprinkled  on  their  bodies  will 
cause  them  to  let  go  and  drop  off.  In- 
jections of  tobacco  smoke  or  solutions 
of  common  salt  will  facilitate  the  detach- 
ment and  removal  of  leeches  from  the 
inside  of  the  mucous  outlets.  Usually 
there  is  no  difficulty  in  checking  he- 
morrhage from  a  leech-bite ;  exposure 
to  the  air,  or  the  application  of  dry 
lint,  is  generally  sufficient.  Should  the 
bleeding  continue  obstinately,  it  may 
be  stopped  by  the  application  of  dos- 
sils of  lint  wet  with  Monsel's  solution 
(liquor  ferri  subsulphatis),  or  a  warm, 
saturated  solution  of  alum ;  or  by 
touching  the  wound  with  a  pencil  of 
nitrate  of  silver,  or  the  actual  cautery 
improvised  by  heating  the  end  of  a 
darning  needle  to  a  dull-red  heat.  If 
all  these  means  fail,  the  bleeding  surface 

must  be  constricted  by  passing  a  threaded  needle  below  it  and  winding  the 
thread  around  beneath  the  ends  of  the  needle. 


Mechanical  loech. 


508  MINOR   SURGERY. 

Tlie  artificial  or  mechanical  leech  is  a  cupping  apparatus  which  combines  in 
a  single  instrument  a  scarificator,  a  cup,  and  an  exhausting  syringe ;  or  con- 
sists of  two  parts,  viz.,  a  small  steel  cylinder  containing  a  lancet  that  is  pro- 
pelled by  a  cord,  or,  better,  projected  by  a  spring,  and  a  hollow  glass  cylinder 
with  a  piston  that  is  moved  by  a  screw  (Fig.  81).  In  using  this  apparatus, 
the  piston  of  the  exhausting  instrument  should  be  drawn  out  slowly,  or  at  the 
same  rate  as  the  blood  flows  from  the  wound.  If  a  vacuum  be  made  over  the 
wound  before  sufficient  blood  has  escaped  to  till  the  cylinder,  its  edge  will 
be  apt  to  compress  the  integuments  to  such  a  degree  as  entirely  to  check  the 
flow  of  blood. 

Venesection. —  For  this  operation,  any  superficial  vein  which  is  acces- 
sible, and  which  can  be  readily  made  prominent,  may  be  selected ;  hence 
the  veins  at  the  bend  of  the  elbow,  those  in  the  vicinity  of  the  inner  ankle, 
and  the  external  jugular  vein,  are  generally  chosen.  In  this  country,  the 
operation  is  usually  performed  either  upon  the  median  basilie  or  the  median 
cej)hcdic  vein.  The  median  basilic  vein  is  generally  larger  in  size,  more 
superficial  in  situation,  and  less  movable  than  the  median  cephalic,  and 
therefore  preference  is  usually  given  to  the  former ;  although  an  operation 
upon  the  latter,  in  consequence  of  its  remoter  position  from  the  course  of  the  bra- 
chial artery,  is  attended  with  less  risk.  At  the  bend  of  the  elbow,  the  median 
basilic  vein  crosses  the  brachial  artery  to  the  inner  side  of  the  tendon  of  the 
biceps  muscle,  and  is  separated  from  the  artery  by  the  dense  bicipital  fascia. 
With  a  little  care  on  the  part  of  the  operator,  the  danger  of  puncturing  the 
artery  may  be  avoided  by  opening  the  vein  either  above  or  below  the  point 
at  which  it  crosses  the  other  vessel. 

There  are  required  for  the  operation  of  venesection,  a  lancet  or  sharp-pointed 
bistoury;  a  piece  of  bandage  or  tape,  from  two  to  four  centimetres  (an  inch  or 
an  inch  and  a  half)  wide;  a  small  compress;  a  bowl;  a  staff;  a  basin  of  water, 
sponge,  and  towel.  The  patient  should  be  in  the  sitting  posture,  grasping  a 
staff  or  other  firm  body  in  his  hand,  with  his  arm  bared  and  extended,  and 
his  forearm  supinated.  The  bandage  or  tape  should  be  applied  to  the  arm 
a  few  centimetres  (an  inch  or  two)  above  the  elbow,  sufficiently  tight  to 
arrest  the  superficial  venous  circulation  without  checking  the  radial  pulse. 
Now,  as  an  assistant  holds  the  bowl  in  a  convenient  position  for  catching  the 
blood,  the  operator  grasps  the  upper  part  of  the  forearm  with  his  left  hand 
in  such  a  way  as  to  enable  him  to  support  the  limb,  and,  at  the  same  time,  to 
control  the  vein  with  his  thumb  just  below  where  the  puncture  is  to  be  made ; 
then,  with  a  lancet  held  firmly  between  the  thumb  and  forefinger  of  his  right 
lini id,  he  quickly  incises  the  distended  vessel  at  a  point  not  directly  over  the 
artery.  The  incision  should  be  about  5  millimetres  (a  fifth  of  an  inch)  long, 
and  in  a  direction  oblique  to  the  long  axis  of  the  vein. 

On  removing  the  thumb  from  the  vein  below  the  incision,  the  blood  will 
flow  in  a  continuous  stream  if  the  vein  be  fairly  opened,  and  if  there  be  no 
obstruction  in  the  wound.  Should  the  escape  of  blood  be  slow,  the  patient 
should  be  directed  to  grasp  firmly  the  staff  or  other  body  that  he  holds  in  his 
hand  ;  or  the  operator  may  stroke  the  forearm  from  the  wrist  towards  the 
el  how.  If  the  position  of  the  forearm  be  changed  from  supination  to  prona- 
tion, after  the  vein  has  been  incised,  the  wound  of  the  skin  will  not  corre- 
spond with  that  of  the  vein,  when  there  may  either  be  an  arrest  of  the  flow 
of  blood,  or  the  blood  may  escape  into  the  cellular  tissue  and  give  rise  to  a 
thrombus.  As  soon  as  the  required  quantity  of  blood  has  been  drawn,  the 
operator  places  the  index  finger  or  thumb  of  his  left  hand  on  the  wound,  and 
quickly  loosens  the  fillet  or  bandage  above  the  elbow.  The  compress  is  now 
placed  on  the  wound  and  secured  by  a  figure-of-eight  bandage,  the  intersec- 


TRANSFUSION   OF   BLOOD.  509 

tions  of  which  should  be  made  directly  over  the  compress ;  a  few  circular 
turns  may  be  carried  around  the  elbow  to  give  additional  security.  It  is  ad- 
visable, also,  to  apply  a  firm  roller  to  the  hand  and  forearm,  to  support  the 
venous  circulation  of  these  parts  till  the  wound  is  healed.  The  arm  should 
be  carried  in  a  sling  for  a  few  days. 

Venesection  may  be  practised  on  the  external  jugular  vein,  whenever,  either 
from  excess  of  fat,  or  in  cases  of  children,  the  veins  at  the  bend  of  the  elbow 
are  not  easily  found.  To  distend  this  vessel,  and,  at  the  same  time,  to 
prevent  the  admission  of  air  when  the  incision  is  made,  the  thumb  of  the 
operator,  or  a  pad,  should  be  placed  over  the  vein  at  the  outer  edge  of  the 
sterno-cleido-mastoid  muscle,  just  above  the  clavicle.  If  the  pad  be  used,  it 
may  be  secured  by  a  bandage  carried  over  the  pad  and  through  the  opposite 
axilla.  The  best  place  to  incise  the  vein  is  over  the  sterno-cleido-mastoid 
muscle ;  the  opening  should  be  parallel  with  the  fibres  of  the  muscle.  By 
making  the  incision  in  this  direction,  the  fibres  of  the  platysma  myoides 
muscle  (which  is  superficial  to  the  vein)  will  be  divided  transversely,  and,  by 
their  retraction,  the  oblique  opening  in  the  vein  will  be  kept  patulous.  In 
order  that  all  risks  of  air  gaining  access  to  the  vein  may  be  avoided,  the 
wound  must  be  securely  closed  before  the  pad  is  removed  from  the  vein  in 
the  supra-clavicular  fossa. 

When  this  operation  is  performed  in  the  veins  of  the  ankle  the  internal 
saphena  is  selected.  That  this  vessel  and  its  tributaries  may  be  fully  dis- 
tended, the  foot  and  ankle  should  be  immersed  in  warm  water  for  a  few  min- 
utes before  the  constricting  band  is  placed  around  the  lower  third  of  the  leg. 
The  internal  saphena  vein,  where  it  passes  up  in  front  of  the  internal  malle- 
olus, should  be  opened  by  an  oblique  incision,  made  from  behind,  forwards 
and  upwards.     The  accompanying  nerve  lies  immediately  behind  the  vein. 

Arteriotomy. — The  vessel  usually  selected  for  this  operation  is  the  tempo- 
ral artery,  above  the  zygoma,  or  one  of  its  two  principal  branches,  either  of 
which  may  be  easily  found.  "Whichever  trunk  be  chosen,  it  must  be  firmly 
held  in  position  by  the  finger  or  thumb  of  the  operator,  placed  on  it  below 
the  point  at  which  the  incision  is  to  be  made.  A  transverse  opening  should 
be  made  in  the  vessel  with  a  sharp-pointed  bistoury  or  lancet,  and,  if  the 
blood  does  not  flow  with  sufficient  freedom,  the  vessel  may  be  cut  entirely 
across.  The  hemorrhage  may  be  checked  b}7  a  firm  compress  laid  on  the 
wound  and  secured  by  a  circular  bandage  of  the  vault  of  the  cranium ;  if 
this  fail  to  arrest  the  bleeding,  both  ends  of  the  vessel  may  be  ligatured  in 
the  wound,  and  the  same  dressing  applied. 


Transfusion  of  Blood. 

This  operation  has  never  found  much  favor  with  the  profession  in  this 
country,  partly  owing  to  the  fact  that  a  very  large  proportion  of  the  patients 
operated  upon  die  (though  not  in  consequence  of  the  operation,  but  rather  in 
spite  of  it),  and  partly  as  a  result  of  the  many  difficulties  attending  the  per- 
formance of  the  operation  itself.  There  are  two  methods  by  which  transfu- 
sion may  be  effected :  the  immediate  or  direct,  and  the  mediate  or  indirect.  By 
the  former,  blood  is  conveyed  directly  and  without  exposure  to  the  air,  from 
the  vessels  of  one  person  to  those  of  another ;  by  the  latter,  it  is  first  drawn 
and  then  injected  either  as  a  whole  or  after  being  deprived  of  its  fibrine.  It 
would  seem,  theoretically  at  least,  that  the  immediate  method  possessed  the 
greater  advantages,  by  virtue  of  the  fact  that  by  it  blood  is  transferred  from 
one  individual  to  another  in  its  natural  state,  and  is  not  contaminated  by 


510 


MINOR   SURGERY. 


being  exposed  to  the  surrounding  media.  Panum,  of  Copenhagen,  and  other 
observers,  have,  however,  demonstrated  by  experiment  that  blood  exposed  to 
the  air  for  a  brief  period,  and  deprived  of  fibrine,  is  not  thereby  rendered 
unfit  for  introduction  into  the  bloodvessels. 

Direct  Transfusion. — The  means  most  commonly  employed  in  direct 
transfusion  are  the  Aveling  syringe  and  Roussel's  apparatus.  The  Aveling 
syringe  is  simply  an  India-rubber  tube,  about  50  centimetres  (19|  inches)  long, 
with  a  small  bulb  in  the  centre,  and  having  metallic  extremities  provided 
with  stopcocks ;  for  connecting  the  tube  with  the  bloodvessels,  there  are  two 
bevel-pointed  metallic  canula?.  A  small,  sharp-pointed  bistoury  and  a  deli- 
cate pair  of  forceps  are  used  for  exposing  and  opening  the  vein. 

In  using  the  Aveling  syringe,  it  is  filled  with  tepid  water,  or  a  weak  saline 
solution,  for  the  purpose  of  displacing  the  air ;  this  is  done  by  placing  the 
rubber  tube,  the  stopcocks  being  open,  in  a  shallow  basin  containing  the 
liquid.  The  person  supplying  the  blood,  sometimes  called  the  blood-donor, 
is  brought  to  the  bedside  of  the  patient  and  directed  to  place  the  arm  from 
which  the  blood  is  to  be  drawn,  nearly  parallel  with  the  patient's  arm.  The 
operator  now  proceeds  to  open  the  most  prominent  vein  in  the  bend  of  the 
patient's  elbow,  and  to  insert  into  it  one  of  the  canulse  filled  with  water, 
with  the  point  directed  towards  the  body,  while  an  expert  assistant,  at  the 
same  time,  introduces  the  other  canula,  also  filled  with  water,  into  the  donor's 
vein;  in  the  latter  the  point  of  the  canula  should  be  directed  towards  the 

Fig.  82. 


Aveling's  transfusion  apparatus.    A  B,  assistant's  hands  holding  the  canula!  in  position  ;  C  D;  operator's  hands, 
compressing  the  bulb  and,  alternately,  the  afferent  and  efferent  tubes. 

hand.  As  the  canulse  are  held  steadily  in  position  by  assistants,  they  are 
quickly  connected  by  the  tube,  the  stopcocks  of  which  are  closed  before  it  is 
taken  out  of  the  basin,  to  prevent  the  escape  of  the  water  which  displaced 
the  air.  Now  on  opening  the  stopcocks,  a  direct  vascular  communication  is 
established  between  the  patient  and  the  donor.  (Fig.  82.)  The  introduction 
of  the  contents  of  the  bulb  into  the  patient's  vein  is  effected  by  the  operator 
slowly  compressing  the  bulb  with  one  hand,  while  he  keeps  the  tube  closed 
on  the  donor's  side  with  the  finger  and  the  thumb  of  the  other  hand.  Then 
by  releasing  the  tube  on  the  donor's  side  of  the  bulb,  and  closing  it  on  the 
patient's  side,  blood  will  flow  from  the  donor's  vein  into  the  bulb  as  it  is 
slowly  permitted  to  expand.  Communication  on  the  donor's  side  is  again 
closed,  and  opened  on  the  patient's  side,  when,  as  the  bulb  is  compressed  a 
second  time,  its  contents  are  driven  into  the  patient's  vein.    By  this  alternate 


TRANSFUSION   OF   BLOOD.  511 

emptying:  and  filling  of  the  bulb,  direct  transfusion  is  effected.  By  bearing 
in  mind  the  fact  that  8  grammes  (2  drachms)  of  blood  are  emptied  by  eacn 
compression  of  the  bulb,  the  quantity  transferred  may  be  readily  determined. 
After  the  operation  is  completed,  the  wounds  of  the  veins  are  treated  as  in 
a  case  of  venesection. 

The  apparatus  devised  by  Rousscl,  for  effecting  direct  transfusion,  is  much 
more  complicated  than  the  Aveling  instrument,  and  hence  its  successful  em- 
ployment necessitates  considerable  familiarity  with  its  use  on  the  part  of  the 
operator.     The  apparatus  (Fig.  83)  consists  of  a  glass  receiver  containing  a 

% 

Fig.  83. 


Roussel's  apparatus  for  transfusion  of  blood. 

lancet,  and  a  Higginson's  pump,  which  connects  the  receiver  with  a  canula 
that  is  to  be  inserted  into  the  patient's  vein.  The  receiver  is  placed  on  the 
blood-donor's  arm,  directly  over  the  vein  from  which  the  blood  is  to  be  ob- 
tained, and  is  retained  there  by  atmospheric  exhaustion.  In  order  to  get  rid 
of  air,  the  apparatus  is  first  filled  with  a  solution  of  bicarbonate  of  sodium  in 
the  proportion  of  2  grammes  (|  drachm)  of  the  salt  to  1  litre  (a  quart)  of 
water;  then  the  donor's  vein  is  punctured  by  means  of  the  lancet  in  the  re- 
ceiver, and,  as  soon  as  the  sodium-solution  is  displaced  by  the  blood,  the  latter 
is  slowly  pumped  into  the  recipient's  vein. 

Indirect  Transfusion. — The  mediate  or  indirect  method  of  transfusing  blood 
has  been  very  often  resorted  to  in  this  country.  In  an  emergency,  this  opera- 
tion may  be  done  with  few  instruments.  The  first  time  that  the  writer  had 
occasion  to  perform  transfusion,  the  instruments  used  were  a  hard  rubber 
syringe,  to  which  was  fitted  a  tubular  needle  (sometimes  used  by  gynaecologists 
in  operations  on  the  female  perineum),  two  porcelain  bowls,  a  linen  strainer, 
a  brush  made  of  fresh  broom-corn,  and  a  sharp-pointed  bistoury.  By  means 
of  these  instruments,  five  ounces  of  defibrinated  blood  were  successfully  in- 
jected into  the  veins  of  a  woman  who  was  moribund  from  excessive  hemor- 
rhage consequent  upon  an  abortion.     The  patient  made  a  quick  recovery. 

Various  plans  and  many  ingenious  apparatuses  have  been  devised  with  a 
view  to  facilitating  the  safe  performance  of  this  operation ;  but  with  care  it 
may  be  done  as  safely  and  as  expeditiously  with  the  simple  instruments  just 
named  as  with  the  most  elaborate  apparatus. 

Hewitt's  Apparatus. — Dr.  Graily  Hewitt  has  devised  an  apparatus  by  which 
blood,  before  it  has  had  time  to  coagulate,  may  be  introduced  into  an  indi- 
vidual's vein.  It  comprises  a  glass  syringe  holding  64  grammes  (2  ounces), 
with  a  piston,  easily  removed  and  inserted,  and  a  curved  nozzle  provided 
with  a  stopper.  There  is  also  a  curved  stylet  and  canula  (the  latter  fitting 
the  nozzle  of  the  syringe),  for  insertion  into  the  recipient's  vein.  In  using 
this  instrument,  the  blood  is  allowed  to  flow  into  the  syringe,  the  piston 
having  been  previously  removed,  and  the  nozzle  closed  with  the  stopper. 
During  this  part  of  the  operation,  the  surgeon  or  a  dextrous  assistant  should 
open  the  recipient's  vein,  and  insert  the  canula  closed  with  the  stylet.     As 


512 


MINOR   SURGERY. 


Fig.  84. 


soon  as  the  syringe  is  full,  the  piston  is  attached,  and  the  nozzle  is  in- 
serted into  the  canula,  the  stopper  and  the  stylet  having  been  taken  out.  The 
blood,  now,  is  slowly  injected  by  forcing  home  the  piston.  In  order  that  more 
blood  may  be  easily  abstracted  for  another  injection,  the  supplier  should  be 
directed  to  keep  the  opening  in  his  vein  closed  with  his  thumb  or  finger  till 
the  syringe  is  cleansed  and  prepared  for  receiving  another  supply.  The  suc- 
cess of  this  operation  depends  upon  the  expedition  with  which  it  is  per- 
formed. JSTot  more  than  two  minutes  should  be  permitted  to  intervene  be- 
tween the  reception  of  the  blood  in  the  syringe  and  its  introduction  into  the 
recipient's  vein ;  otherwise,  coagulation  of  the  blood  is  liable  to  take  place, 
which  would  seriously  embarrass  the  future  steps  of  the  operation. 

Allen's  Apparatus. — Mediate  transfusion  is  commonly  effected  in  this  city 
(Philadelphia)  by  means  of  an  apparatus  that  was  first  suggested  by  Dr.  J. 
G-.  Allen,  and  subsequently  modified  by  Dr.  T.  G.  Morton  and  the  writer. 
The  apparatus  consists  of  a  blood-can ;  a  strainer,  either  metallic  or  linen ;  a 
graduated  glass  sy ringe  holding  five  or  six  ounces ;  a  curved  canula  with  its 
point  bevelled  on  the  convex  side ;  a  brush,  either  made  of  fine  wire  or  of 
fresh  broom-corn,  and  a  lancet  or  sharp-pointed  bistoury.  The  blood-can  has 
two  compartments,  an  outer  for  hot  water,  and  an  inner,  conical  in  shape,  and 
extending  down  into  the  former,  for  the  reception  of  the  blood  as  it  flows 
from  the  supplier's  vein.  To  the  side  of  the  can  is  affixed  a  clinical  thermo- 
meter, the  curved  bulb  of  which  projects  into  the  hot-water  chamber ;  there 
is  likewise  a  short  tube  communicating  with  this  chamber  for  the  introduc- 
tion of  hot  water.  The  conical 
wire  strainer  is  made  to  fit  ac- 
curately the  conical  blood-cham- 
llfl  ^er.  A  short  piece  of  flexible 
tubing  is  used  to  connect  the 
nozzle  of  the  syringe  with  the 
canula,     (Fig.  84.) 

In  the  employment  of  this 
apparatus,  the  first  step  is  to  fill 
the  outer  chamber  of  the  blood- 
can  with  water  at  a  temperature 
of  110°  F. ;  should  the  temper- 
ature fall  below  100°  F.  during 
the  performance  of  the  opera- 
tion, more  hot  water  at  the 
former  temperature  should  be 
added.  The  syringe  should  be  kept  in  hot  water  till  it  is  required.  The 
supplier's  vein  should  now  be  opened,  as  in  venesection,  and,  as  the  blood 
escapes,  the  blood-can  with  the  conical  strainer  should  be  held  in  a  convenient 
position  for  receiving  it,  Before  the  blood  in  the  can  begins  to  coagulate,  it 
should  be  slowly  stirred  with  the  wire  brush  to  separate  the  fibrine ;  and  from 
time  to  time  the  brush  should  be  cleansed  in  warm  water  to  keep  it  free  from 
coagula.  If  desirable,  the  abstraction  of  the  blood  and  its  preparation  for 
injection  may  be  attended  to  by  an  assistant  in  an  adjoining  room,  while  the 
surgeon  himself  lays  bare  the  recipient's  vein  and  inserts  the  point  of  the 
canula.  It*  a  sharp-pointed  canula  be  used,  its  point  may  be  thrust  through 
the  thin  wall  of  the  vein  into  its  cavity;  but  if  the  canula  be  blunt,  it  is  a 
safer  plan  to  place  a  ligature  around  the  vessel  on  the  distal  side,  and  make 
an  opening  in  it  for  the  introduction  of  the  canula. 

As  soon  as  the  fibrine  of  the  blood  in  the  can  is  separated,  the  strainer  is 
removed,  and  with  it  all  fragments  of  clot  and  foreign  matter,  leaving  nothing 
but  defibrinated  blood  in  the  can,  surrounded  with  hot  water.     The  syringe 


Allen's  transfusion  apparatus,  modified. 


TRANSFUSION   OF   BLOOD. 


513 


with  the  flexible  tube  attached  is  then  filled  with  defibrinated  blood,  and 
quickly  connected  with  the  canula  which  has  previously  been  introduced  into 
the  recipient's  vein.  The  blood  should  be  slowly  and  .steadily  injected.  If 
air  be  drawn  into  the  syringe  with  the  blood,  it  may  be  expelled  before  the 
syringe  is  attached  to  the  canula  by  holding  the  syringe  in  a  vertical  position 
with  the  nozzle  upwards,  and  pushing  in  the  piston  sufficiently  far  to  displace 
the  air.  Should  it  be  deemed  necessary  to  introduce  more  than  one  syringc- 
ful,  the  syringe  may  be  charged  again  with  defibrinated  blood,  and  the  injec- 
tion repeated.  The  wounds  of  the  veins  of  the  supplier  and  the  recipient 
should  be  treated  as  in  a  case  of  ordinary  venesection. 

Many  other  ingenious  instruments  have  been  devised  for  effecting  mediate 
transfusion,  among  which  may  be  mentioned  Collin's  apparatus,  which  is 
used  in  the  French  army,  and  llasse's  syringe.  In  Ilasse's  syringe,  the  piston 
is  moved  by  a  female  screw,  which  enables  the  operator  to  regulate  the  flow 
of  blood  with  the  utmost  nicety.  Transfusion  by  hydrostatic  pressure  is 
urgently  recommended  by  Dr.  Friedrich  Esmarch,  who  considers  it  free  from 
many  of  the  objections  which  have  been  urged  against  the  use  of  the  syringe. 

Arterial  Transfusion,  as  recommended  by  Hitter,  is  occasionally  prac- 
tised. In  this  operation,  defibrinated  venous  blood  is  injected  into  an  artery 
(usually  the  radial  above  the  wrist,  or  the  posterior  tibial  behind  the  inner 
malleolus),  towards  the  distal  extremity  of  the  limb.  The  artery  is  exposed 
and  secured  by  a  ligature ;  it  is  then  opened  on  the  distal  side  of  the  ligature 
by  a  valvular  wound,  into  which  the  point  of  a  canula  or  the  nozzle  of  a 
syringe  is  introduced.  When  the  operation  is  completed,  the  artery  is  cut 
across  and  the  peripheral  end  ligatured. 

Auto-transfusion  is  a  term  applied  to  an  expedient  that  may  be  resorted 
to  in  eases  of  excessive  hemorrhage  to  support  a  moribund  patient  till  trans- 
fusion can  be  performed,  or  other  means  of  resuscitation  adopted.  It  consists 
in  the  application  of  elastic  bandages,  or,  if  these  be  not  at  hand,  muslin 
bandages,  to  the  extremities,  for  the  purpose  of  forcing  the  blood  towards  the 
vascular  and  nervous  centres. 


Intra-venous  Injections  of 
sometimes  employed,  as  a  sub- 
stitute for  transfusion,  after  ex- 
cessive hemorrhage,  and  in  dis- 
eases which  greatly  deteriorate 
the  quality  of  the  blood,  as  per- 
nicious anaemia,  epidemic  cho- 
lera, carbonic  acid  poisoning, 
etc.  In  1850,  Dr.  E.  M.  Hod- 
der,  of  Toronto,  first  made  use 
of  milk  injections  in  the  treat- 
ment of  cholera  collapse.  Since 
then,  this  operation  has  been 
repeated  by  Dr.  J.  W.  Howe, 
Dr.  T.  Gaillard  Thomas,  Dr. 
Bullard,  and  others,  in  the 
treatment  of  various  disorders, 
with  more  or  less  benefit  to  the 
patients.  The  writer  has  him- 
self resorted  to  infusion  of  milk 
vol.  i. — 33 


Milk,  or  of  various  Saline  Solutions,  are 


Fig.  85. 


Funnel  and  tube  for  intra-venous  injection  of  milk. 


514  MINOR   SURGERY. 

eleven  times,  with  sufficient  success  to  encourage  him  in  the  belief  that,  under 
certain  circumstances,  the  procedure  is  perfectly  justifiable,  and  that  milk 
introduced  into  the  system  in  this  way  may  become  a  valuable  therapeutic 
resource.  Intra-venous  injection  is  an  easier  operation  than  transfusion,  and 
is  most  conveniently  effected  by  hydrostatic  pressure.  The  apparatus  used 
by  the  writer  consists  of  a  glass  funnel  holding  about  160  grammes  (5  ounces), 
connected  with  an  India-rubber  tube  to  which  is  attached  a  small  curved 
canula  provided  with  a  stopcock.  (Fig.  85.)  A  cup-shaped  strainer  of  fine 
wire,  made  to  fit  the  expanded  extremity  of  the  funnel,  is  an  important  part 
of  the  apparatus.     (Fig.  86.) 

Fig.  86. 


Strainer  for  intra-venous  injection  of  milk. 

Either  cow's  or  goat's  milk  may  be  used,  and,  as  it  is  absolutely  essential  that 
the  milk  be  perfectly  fresh,  and  alkaline  or  neutral  in  reaction,  it  should  be 
taken  from  the  animal  immediately  before  it  is  injected.  The  surgeon  exposes 
a  prominent  vein  in  the  bend  of  the  patient's  elbow,  and  raises  it  up  by  passing  a 
probe  or  director  beneath  it,  while  an  assistant  fills  the  apparatus  by  pouring  the 
milk  into  the  funnel  through  the  wire  strainer.  In  order  that  no  air  may  be 
left  in  the  apparatus,  the  canula  with  the  stopcock  open  is  held  vertically  along- 
side of  the  funnel,  and,  as  the  milk  begins  to  flow  from  the  canula,  the  stopcock 
is  closed ;  by  this  plan  the  milk  is  retained  in  the  canula  by  atmospheric 
pressure.  The  sharp  point  of  the  canula  is  now  thrust  into  the  lumen  of  the 
vein  (or,  if  the  vein  be  small  or  collapsed,  a  V-shaped  incision  may  be  made 
in  it  for  the  canula),  when,  on  opening  the  stopcock  and  raising  the  funnel 
above  the  level  of  the  patient's  arm,  the  milk  will  flow  into  the  vessel.  The 
rate  at  which  the  milk  enters  the  vein  may  be  regulated  by  the  stopcock,  or 
by  varying  the  height  at  which  the  funnel  is  held  above  the  arm. 


Artificial  Respiration. 

Artificial  respiration  is  resorted  to  in  cases  of  threatened  death  from 
apncea  consequent  upon  drowning,  inhalation  of  irrespirable  gases,  profound 
ansesthetization,  or  other  causes  that  act  by  temporarily  checking  or  inter- 
fering with  the  function  of  breathing.  Two  conditions  are  essentially  neces- 
sary to  the  successful  application  of  this  procedure:  these  arc  (1)  an  unob- 
structed passage  for  the  entrance  of  air  to  the  lungs,  and  (2)  the  absence  of 
all  obstacles  to  free  expansion  of  the  chest-walls,  itence  mucus,  free  liquids, 
or  foreign  bodies  in  the  air-]  lassages  must  be  removed — if  necessar}T,  by  trache- 
otomy ;  and  all  bands  or  tight  clothing  around  the  chest  and  neck  must  be 
loosened. 

Mouth  to  Moutii  Inflation  is  a  method  of  practising  artificial  respiration 
sometimes  adopted  in  cases  of  great  urgency,  as  a  temporary  expedient  till 
other  more  efficient  measures  may  be  instituted.  It  is  especially  applicable 
to  cases  of  children  under  six  months  of  age,  in  consequence  of  the  weak  and 
inelastic  condition  of  their  chest-walls.     Instead  of  the  operator  applying  his 


ARTIFICIAL    RESPIRATION.  515 

mouth  to  that  of  the  patient,  air  may  be  introduced  into  the  lungs  through 
a  flexible  catheter  passed  into  the  trachea. 

The  Bellows  may  be  employed  as  a  means  of  forcing  air  into  the  lungs. 
Dr.  Richardson,  of  London,  has  devised  a  "pocket-bellows"  (Fig.  87)  which 

Fig.  87. 


A 

Richardson's  bellows  for  artificial  respiration.     A,  bulb  for  filling  the  lungs  ;  B,  bulb  for  exhausting  them. 

consists  of  two  elastic  bulbs  terminating  in  a  single  tube.  This  tube  is 
inserted  into  the  nostril,  and,  the  other  nostril  and  the  mouth  being  closed, 
air  may  be  driven  into  the  lungs  by  compressing  one  of  the  bulbs  (A),  and 
withdrawn  by  compressing  the  other  (B).  This  is  an  ingenious  imitation  of 
natural  respiration.  The  entrance  of  air  into  the  oesophagus,  when  either  of 
the  two  methods  just  described  is  practised,  may  be  prevented  by  pressing 
the  larynx  upwards  and  backwards. 

Howard's  Direct  Method  of  Artificial  Respiration. — The  three  methods 
by  which  artificial  respiration  may  be  most  effectively  practised  are  Dr. 
Benjamin  Howard's  "Direct  Method,"  Sylvester's  Method,  and  Marshall 
Hall's  "Ready  Method."  In  this  country,  the  "direct  method"  is  generally 
acknowledged  to  be  the  best.  It  has  been  adopted  by  the  United  States 
Government  Life  Saving  Service,  the  Life  Saving  Society  of  New  York,  etc. 
Dr.  Howard  gives  the  following  rules  for  the  direct  method : — 

Rule  I — "To  drain  off  Water  from  Chest  and  Stomach.  Instantly  strip  the  patient 
to  the  waist.  Place  him  face  downwards,  the  pit  of  the  stomach  being  raised  above  the 
level  of  the  mouth  by  a  large,  hard  roll  of  clothing  placed  beneath  it.  Throw  your 
weight  forcibly  two  or  three  times,  for  a  moment  or  two,  upon  the  patient's  back,  over 
roll  of  clothing,  so  as  to  press  all  fluids  in  the  stomach  out  of  the  mouth." 

The  above  ride  is  to  be  followed  only  in  case  of  drowning ;  in  apnoea  from  other 
causes  it  is  to  be  omitted. 

Rule  II — "  To  perform  Artificial  Breathing.  Quickly  turn  the  patient  upon  his 
back,  the  roll  of  clothing  being  so  placed  beneath  as  to  make  the  breast-bone  the  highest 
point  of  the  body.  Kneel  beside  or  astride  patient's  hips.  Grasp  front  part  of  the 
chest  on  either  side  of  the  pit  of  the  stomach,  resting  your  fingers  along  the  spaces  be- 
tween the  short  ribs.  Brace  your  elbows  against  your  sides,  and,  steadily  grasping  and 
pressing  forwards  and  upwards,  throw  your  whole  weight  upon  chest,  gradually  increas- 
ing the  pressure  while  you  can  count  one — two — three.  Then  suddenly  let  go  with  a 
final  push,  which  springs  you  back  to  your  first  position.  Rest  erect  upon  your  knee 
while  you  can  count  one — two  ;  then  make  pressure  again  as  before,  repeating  the  entire 
motions  at  first  about  four  or  five  times  a  minute,  gradually  increasing  to  about  ten  or 
twelve  times.  Use  the  same  regularity  as  in  blowing  bellows,  and  as  is  seen  in  natural 
breathing,  which  you  are  imitating.  If  another  person  be  present,  let  him  with  one 
hand,  by  means  of  a  dry  piece  of  linen,  hold  the  tip  of  the  tongue  out  of  one  corner  of 
the  mouth,  and  with  the  other  hand  grasp  both  wrists  and  pin  them  to  the  ground  above 
the  patient's  head." 

Sylvester's  Method. — The  patient,  with  all  tight  clothing  and  bands  re- 
moved or  loosened,  is  placed  on  his  back  on  a  flat  surface,  his  head  and  shoul- 


516  MINOR   SURGERY. 

ders  being  supported  by  his  coat  or  some  other  garment  folded  into  a  broad 
cushion.  The  mouth  being  cleared  from  all  foreign  substances,  the  tongue  is 
drawn  forwards,  and  secured  to  the  chin  by  a  piece  of  tape  or  string  tied 
around  it  and  the  lower  jaw;  or  the  tongue,  with  a  piece  of  linen,  or  a  pocket 
handkerchief,  around  it,  may  be  pulled  forwards  and  held  by  an  assistant. 
Now,  the  operator,  kneeling  at  the  patient's  head,  grasps  the  arms  at  the  el- 
bows, and  carries  them  first  outwards,  and  then  upwards,  till  the  hands  are 
brought  into  contact  with  each  other  above  the  head ;  they  are  kept  in  this 
position  for  two  seconds,  after  which  they  are  brought  slowly  back  to  the 
sides  of  the  thorax,  and  pressed  gently  against  it  for  two  seconds.  These 
movements  are  gently  and  deliberately  repeated  fifteen  times  in  a  minute, 
until  a  spontaneous  effort  to  breathe  is  made,  or  until  it  is  evident  that  further 
exertion  is  useless. 

Marshall  Hall's  "Ready  Method." — To  clear  the  mouth  and  secure  free 
entrance  to  the  larynx,  the  patient  is  turned  on  his  face,  with  one  wrist  under 
his  forehead  and  a  folded  coat  or  other  article  of  dress  beneath  his  chest. 
Respiration  is  now  to  be  imitated  by  "  turning  the  body  gently  on  the  side 
and  a  little  beyond,  and  then  briskly  on  the  face,  alternately."  Each  time 
the  body  is  brought  into  the  prone  position,  firm  compression  is  to  be  made 
on  the  posterior  aspect  of  the  thorax.  As  in  the  methods  already  described, 
the  manipulations  designed  to  imitate  respiration  are  repeated  fifteen  times 
in  a  minute,  for  two  or  three  hours,  unless  resuscitation  is  sooner  accomplished. 

The  efforts  of  the  operator  should  not  immediately  cease  when  the  first 
natural  respiratory  movement  is  detected,  but  they  should  be  continued  in 
such  a  way  as  to  coincide  with  the  spontaneous  inspiratory  and  expiratory 
motions,  until  the  breathing  becomes  regular.  Other  agencies,  such  as  aqua 
ammonise  passed  back  and  forth  beneath  the  nostrils,  cold  water  dashed  on 
the  surface  of  the  body,  etc.,  may  aid  in  exciting  respiration.  The  tempera- 
ture of  the  body  may  be  restored  by  friction  applied  by  the  hands  of  assistants 
to  all  parts  of  the  surface,  by  the  hot-water  or  hot-air  bath,  warm  coverings, 
etc.  As  soon  as  the  patient  becomes  capable  of  swallowing,  he  should  be 
given  hot  coffee  or  tea,  or  brandy  or  whiskey  properly  diluted.  After 
respiration  has  become  normal,  the  patient  must  be  closely  watched,  in  order 
that  the  first  signs  of  secondary  apncea  may  be  instantly  detected,  and  that 
suitable  measures  to  avert  it  may  be  promptly  adopted. 

Vaccination. 

Vaccination  is  a  minor  surgical  operation  which  every  practising  physician 
is  expected  to  be  able  to  perform  when  occasion  demands.  Although  in  itself 
exceedingly  simple,  yet,  unless  the  operation  be  carefully  done,  failure  to 
afford  that  protection  against  smallpox  which  is  reasonably  expected,  is  liable 
to  result.  Vaccination  may  be  safely  employed  in  the  case  of  any  healthy 
individual,  at  almost  any  period  of  life.  Children  should  be  vaccinated  before 
they  arc  three  months  old,  unless  there  be  special  contra-indication  to  the  pro- 
cedure ;  in  id,  in  the  event  of  exposure  to  smallpox,  even  at  an  earlier  age — 
immediately  after  birth  if  necessary.  Vaccination  may  be  effected  by  the 
use  of  two 'kinds  of  lymph,  humanized  and  bovine.  Humanized  lymph  may 
be  used  in  one  of  two' forms,  either  as  a  viscid  fluid  taken  from  a  well-formed 
vaccine  vesicle  on  the  eighth  or  ninth  day,  or  as  a  scab  or  crust  which  has 
separated  spontaneously  about  the  twentieth  day.  The  former  is  generally 
considered  more  effective  than  the  latter,  yet  the  dried  scab  is  more  commonly 
employed  in  this  country.     Bovine  or  animal  virus  is  obtained  directly  from 


VACCINATION.  517 

the  udder  and  teats  of  the  cow,  and  is  made  available  by  being  allowed  to 
dry  on  slips  of  ivory,  quill,  or  whalebone.  Humanized  lymph  in  either  form 
must  be  free  from  blood  and  pus,  and,  when  kept  for  use,  must  be  preserved 
from  the  action  of  heat  and  moisture  ;  otherwise  its  employment  may  be  pro- 
ductive of  serious  results.  In  this  country,  the  suppliers  of  animal  virus  en- 
velop the  charged  ivory  and  quill  points  in  antiseptic  cotton,  which  is  sur- 
rounded with  water-proof  material. 

The  only  instrument  needed  for  effecting  vaccination  is  a  common  lancet, 
one  which  is  somewhat  dull  being  usually  preferred,  as  drawing  less  blood. 
By  means  of  this  simple  instrument,  the  operation  may  be  done  quite  as  satis- 
factorily as  with  any  of  the  many  ingenious  devices  which  have  been  sug- 
gested for  the  purpose.  That  the  lancet  may  not  be  the  means  of  carrying 
contagion,  it  should  be  kept  perfectly  clean.  The  place  usually  selected  for 
the  insertion  of  vaccine  virus,  is  on  the  outer  side  of  the  left  arm,  near  the 
attachment  of  the  deltoid  muscle,  although  the  operation  may  be  performed 
on  almost  any  part  of  the  body.  Whenever  practicable,  arm-to-arm  vaccina- 
tion is  to  be  preferred  to  all  other  methods.  In  this  mode  of  proceeding,  fluid 
lymph  is  taken  directly  from  a  well-formed  vesicle  on  the  eighth  day,  when 
its  contents  are  probably  the  most  effective,  and  inserted  into  the  skin.  If 
ivory  or  quill  slips  be  used,  the  dried  lymph  must  be  softened  by  holding  the 
points  in  the  steam  of  hot  water,  or  by  dipping  them  in  warm  water ;  or,  if 
the  crust  be  employed,  it  must  be  reduced  to  a  semi-liquid  condition  with  a 
little  water  or  glycerine. 

There  are  several  ways  in  which  vaccine  virus  may  be  inserted  into  the 
skin,  any  one  of  which,  if  carefully  practised,  will  undoubtedly  prove  suc- 
cessful. Probably,  the  one  most  commonly  employed  in  this  country  is  that 
of  abrasion  or  "  cross-scratch  ;"  it  certainly  seems  to  be  the  method  most  usu- 
ally successful  when  dry  lymph  is  used.  In  making  the  abrasion,  the  ope- 
rator grasps  the  left  arm  of  the  patient  in  such  a  manner  as  to  put  the  skin 
overlying  the  insertion  of  the  deltoid  muscle  on  the  stretch.  He  then  with 
the  lancet  scratches  off  the  epithelium  and  exposes  the  absorbing  surface  of 
the  cutis  vera  ;  the  appearance  of  bloody  oozing  is  an  indication  that  the 
cutis  has  been  sufficiently  denuded.  On  this  surface,  after  the  blood  has  been 
wiped  off,  the  lymph  is  smeared,  either  with  the  flat  surface  of  the  lancet- 
blade,  or  with  an  ivory  or  quill  point.  The  part  is  to  be  left  uncovered  till 
the  lymph  dries.  There  is  no  need  of  making  any  topical  application  subse- 
quently ;  the  only  precaution  necessary  is  to  keep  the  part  from  being  chafed 
or  scratched  till  the  scab  falls  off 

Another  plan,  peculiarly  suited  to  arm-to-arm  vaccination,  is  to  insert  the 
lymph  into  small  punctures  made  in  the  skin  with  the  point  of  a  lancet. 
These  punctures  should  be  made  obliquely  from  above  downwards,  and  should 
extend  well  into  the  cutis.  The  virus  is  introduced  on  the  point  of  a  lancet, 
or  on  an  ivory  or  quill  point.  The  valvular  character  of  the  wound  favors 
the  retention  of  the  lymph.  Instead  of  making  four  or  five  punctures  as 
above  described,  multiple  punctures  may  be  made,  and  the  lymph  rubbed 
over  the  wounded  surface ;  or  the  lymph  may  be  first  smeared  on  the  surface 
and  then  pricked  in,  as  in  tattooing. 

Revaccination  is  imperatively  called  for  in  cases  in  which  primary  vacci- 
nation has  entirely  failed,  or  lias  been  modified  by  causes  not  apparent.  It  is 
also  advisable  to  revaccinate  at  or  shortly  after  puberty,  even  when  there  are 
unmistakable  evidences  of  a  successful  and  thorough  primary  vaccination. 
Some  authorities  go  further,  and  advise  a  repetition  of  the  operation  once  in 
seven  years,  and  likewise  whenever  an  epidemic  of  smallpox  is  prevailing. 
The  methods  by  which  revaccination  is  effected  differ  in  no  way  from  those 
adopted  for  the  primary  operation. 


518 


MINOR    SURGERY. 


Hypodermic  Injections. 

Hypodermic  injection  is  a  simple  method  of  introducing  certain  drugs, 
especially  anodynes,  into  the  system,  and  is  frequently  resorted  to  by  surgeons 
in  cases  in  which  a  more  prompt  and  decided  impression  is  desired  than  could 
be  obtained  were  the  same  remedies  administered  either  by  the  mouth  or  by 
the  rectum.  Although  this  operation,  in  the  hands  of  an  experienced  person, 
is  one  of  extreme  simplicity,  and  free  from  danger,  yet  unpleasant  and  even 
fatal  consequences  have  followed  its  employment  when  incautiously  per- 
formed ;  hence,  as  a  rule,  the  surgeon  should  either  do  the  operation  himself, 
or  intrust  it  to  an  intelligent  assistant. 

The  instrument  employed  consists  of  a  small  syringe,  holding  about  30 
minims,  with  an  adjustable  nozzle,  which  is  a  hollow  needle.    (Fig.  88.)    The 


Syringe  for  hypodermic  injections. 


barrel  is  made  of  either  glass,  hard-rubber,  metal,  or  a  combination  of  glass 
and  metal.  In  order  that  the  syringe  may  be  air-tight,  the  piston  must  accu- 
rately fit  the  cylinder ;  hence  the  calibre  of  the  latter  must  be  the  same  through- 
out. A  glass  syringe  may  be  graduated  to  minims,  either  on  the  barrel  or  on 
the  piston-rod  ;  other  forms  of  the  instrument  have  the  piston-rod  graduated. 
The  perforated  needle  may  be  attached  to  the  barrel  by  either  a  screw  or  a 
socket-joint.  The  metallic  syringe  is  the  one  to  which  the  writer  gives  pre- 
ference. This  has  two  delicate  needles  with  lancet-shaped  points,  which  are 
attached  to  the  barrel  by  a  screw-joint.  It  is  provided  with  a  screw-cap  that 
is  to  be  kept  on  the  end  of  the  barrel  when  the  instrument  is  not  in  use,  in 
order  that  the  piston  may  always  be  moist,  and  the  cylinder  free  from  dirt. 
A  delicate  piece  of  annealed  wire,  sharp  pointed  and  attached  to  a  small 
handle,  will  be  found  useful  to  remove  dirt  or  moisture  from  the  needles 
whenever  they  become  clogged;  this  may  be  dispensed  with,  however,  if  the 
<i)  terator  will  introduce  a  fine  wire  into  the  needle  immediately  after  it  is  used. 
Hard-rubber  syringes,  with  gold  or  platinum  needles,  are  best  suited  for  the 
injection  of  certain  mineral  substances,  and  particularly  iodine. 

The  drug  most  commonly  employed  by  the  surgeon  for  subcutaneous  injec- 
tion, is  the  sulphate  of  morphia.  When  it  is  extensively  used  in  this  way, 
as  in  hospital  practice,  Magendie's  solution  will  be  found  the  most  convenient 
preparation,  lor  eight  minims  of  this  solution  represent  about  a  fourth  of  a 
grain  of  the  sulphate  of  morphia.  As,  however,  the  solution  soon  loses  its 
strength  by  the  development  in  it  of  a  penicillum,  and  is  thereby  rendered 
unlit  for  hypodermic  use,  it  is  a  better  plan,  in  private  practice,  for  the  sur- 
geon to  cany  the  drug  in  powder,  and  to  make  a  fresh  solution  whenever 
occasion  demands  its  employment.  The  writer  is  in  the  habit  of  carrying 
morphia  in  quarterof  a  grain  powders, put  up  in  tinfoil.  When  an  injection 
ir*  to  be  given,  one  of  these  powders  maybe  quickly  dissolved  in  ten  or  twenty 
minims  of  fresh  water,  the  quantity  of  the  liquid  being  accurately  determined 
by  being  drawn  first  into  the  s}'ringe  and  then  injected  into  a  spoon.     The 


ASPIRATION.  519 

other  alkaloids,  viz.,  atropia,  strychnia,  ergotina,  pilocarpin,  etc.,  cannot  be 
managed  in  this  way,  hence  they  are  kept  in  solution  ready  for  use.  What- 
ever drug  is  injected  beneath  the  skin,  its  solution  should  be  free  from  for- 
eign matter,  and  as  nearly  neutral  as  possible,  so  that  it  will  not  excite  undue 
irritation  of  the  tissues.  Of  course,  this  caution  does  not  apply  to  those  in- 
jections that  are  sometimes  employed  for  the  express  purpose  of  exciting 
irritation,  as  in  the  treatment  of  enlargements  of  the  thyroid  body,  bursal 
enlargements,  cases  of  neuralgia,  etc. 

In  giving  a  subcutaneous  injection,  the  operator  pinches  up  a  fold  of  integu- 
ment between  the  thumb  and  first  two  lingers  of  his  left  hand,  and,  holding  the 
charged  syringe  firmly  in  his  right,  quickly  thrusts  the  point  of  the  needle 
into  the  superficial  fascia  parallel  with  the  fold.    (Fig.  89.)      The  needle 

Fig.   89. 


Mode  of  giving  a  hypodermic  injection. 

should  be  carried  fully  two  centimetres  (three-fourths  of  an  inch)  into  the 
tissue,  and  its  point  should  be  moved  about,  to  make  sure  that  it  is  not  in 
the  deeper  layers  of  the  true  skin.  The  contents  of  the  syringe  should  be 
forced  out  slowly,  after  which  the  needle  should  be  quickly  removed,  and  the 
puncture  closed  by  the  pressure  of  the  finger  for  a  few  seconds,  to  prevent  the 
escape  of  any  of  the  fluid,  and  to  arrest  the  slight  bleeding  which  sometimes 
follows  the  operation.  Should  the  patient  be  timid  and  dread  the  slight 
pain  of  an  injection,  the  sensibility  of  the  skin  may  be  diminished  by  the 
use  of  local  anresthesia,  or  the  same  end  may  be  accomplished  with  less  trouble 
by  firmly  pinching  the  fold  of  integument  as  the  needle  enters  the  skin.  As 
a  rule,  the  fluid  should  be  injected  into  the  superficial  fascia ;  in  some  cases 
of  paralysis,  however,  in  which  strychnia  is  employed,  the  injection  is  made 
directly  into  the  affected  muscle,  and  deep  injections  of  chloroform  or  ether  are 
resorted  to  in  some  cases  of  neuralgia.  The  pain  and  redness  which  occa- 
sionally follow  a  hypodermic  injection,  may  be  allayed  by  the  application  of 
a  cold  compress,  or  of  one  saturated  with  lead-water  and  laudanum. 

Certain  localities  should  be  avoided  in  practising  hypodermic  medication; 
these  are  salient  points  of  the  skeleton,  the  immediate  vicinity  of  large  super- 
ficial veins,  and  parts  which  will  be  necessarily  subjected  to  pressure.  It  is 
not  well  to  give  subcutaneous  injections  in  parts  that  are  inflamed.  The 
places  usually  selected  for  the  injection  of  anodynes  are  the  outer  surface  ot 
the  forearm  and  the  anterior  surfaces  of  the  arm  and  thigh. 

Aspiration. 

This  operation,  which  consists  in  removing  the  liquid  contents  of  a  cavity 
without  the  admission  of  air,  is  performed  by  means  of  an  apparatus  called 


520 


MINOR    SURGERY. 


an  aspirator.  The  two  varieties  of  the  apparatus  in  common  use  at  the 
present  time  are  designated  by  the  names  of  the  inventors,  Dieulafoy  and 
Potain.  Formerly  aspiration  was  confined  principally  to  the  evacuation  of 
fluid  collections  in  the  chest ;  the  instruments  employed  for  this  purpose 
were  the  piston-trocar  and  the  suction-trocar,  the  latter  having  been  perfected 
by  Dr.  M.  Wyman  and  Dr.  Bowditch.  These  instruments  are  seldom  used 
now,  experience  having  demonstrated  that,  although  simple  in  construction 
and  easily  managed,  they  are  not  as  efficient  as  either  of  the  two  forms  of 
apparatus  previously  mentioned. 

M.  Dieulafoy's  aspirator  consists  of  an  exhausting  pump,  composed  of  a 
glass  cylinder  partially  incased  in  metal ;  a  set  of  sharp-pointed  canulse  of 
various  sizes  ;  and  two  pieces  of  flexible  tubing.  The  nozzle  of  the  pump 
has  a  short  tube  connected  at  its  side,  at  right  angles,  a  stopcock  at  the 
junction  controlling  both  tube  and  nozzle.  (Fig.   90.)     A  canula  is  attached 

Fig.  90. 


Dieulafoy's  aspirator. 

to  the  nozzle  by  one  of  the  pieces  of  tubing,  the  other  piece  of  tubing  being 
connected  with  the  side-tube,  and  its  free  end  placed  in  a  basin  partly  filled 
with  water.  The  canula  is  quickly  thrust  into  the  cavity  to  be  evacuated ; 
and  when  the  stopcock  is  turned  so  as  to  open  the  nozzle  and  close  the  side- 
tube,  and  the  piston  of  the  pump  is  slowly  drawn  up,  the  fluid  rushes  into 
the  pump  to  fill  the  vacuum.  On  reversing  the  stopcock  so  as  to  close  the 
nozzle,  and  pushing  down  the  piston,  the  fluid  is  driven  through  the  side- 
tube  into  the  basin  of  water.  These  manipulations  are  repeated  till  the 
cavity  is  emptied. 

The  other  form  of  aspirator,  devised  by  Potain,  is  a  modification  of  the 
one  just  described,  and  is  probably  superior  to  it  in  many  respects.  The 
parts  <>f  this  apparatus  arc  an  air-pump;  blunt  canulae  of  various  calibres, 
with  blunt  and  sharp-pointed  stylets;  an  India-rubber  stopper  perforated 
with  two  curved  tubes,  each  having  a  stopcock;  a  bottle;  and  rubber 
tubing.  (Fig.  91.)  The  stopper  is  conical  in  shape,  and  of  a  size  rendering 
it  adaptable  to  the  necks  of  ordinary  bottles  varying  in  capacity  from  a  pint 
to  half  a  gallon  or  more.  The  bottle  is  first  exhausted  of  air  by  the  air- 
pump;  then  the  canula,  inclosing  the  sharp-pointed  stylet,  being  attached  to 
one  of  the   tubes   in   the   stopper   by  a  piece  of  flexible  tubing,  is  pushed 


SURGICAL   USES    OF    ELECTRICITY. 


521 


through  the  integuments  into  the  cavity  containing  the  fluid  to  be  evacuated. 
On  withdrawing  the  stylet  and  opening  the  stopcock,  the  fluid  passes  quickly 
into  the  bottle.  If  there  be  more  fluid  than  one  bottle  will  hold,  the  step- 
cock  of  the  tube  connected  with  the  canula  may  be  closed,  the  stopper 


Potain's  aspirator. 

removed,  and  the  bottle  emptied ;  it  is  then  to  be  re-exhausted  by  the  air- 
pump.  Occasionally,  as  in  the  case  of  cold  abscesses,  the  flow  of  pus  is 
suddenly  stopped  by  a  small  mass  of  lymph  or  cheesy  matter  becoming 
lodged  in  the  canula.  Such  an  obstruction  may  be  easily  removed  by  pass- 
ing a  blunt  stylet  or  plunger  through  the  canula.  With  Potain's  aspirator 
all  unpleasant  odors  are  conveyed  with  the  pus  into  the  bottle-reservoir,  and 
therefore  do  not  escape  into  the  patient's  room.  This  is  an  advantage  not 
possessed  by  any  other  variety  of  the  instrument.  As  the  canulse  of  this 
apparatus  are  blunt-pointed,  they  will  not  wound  the  delicate  inner  surface 
of  the  sac  of  an  abscess  as  its  walls  collapse ;  hence  hemorrhage  into  the 
cavity  of  an  abscess  is  less  liable  to  follow  the  use  of  this  aspirator  than  of 
those  that  are  provided  with  sharp-pointed  cannlre. 

In  aspirating  an  abscess,  it  is  advisable  to  use  a  large  canula,  in  order  that 
the  pus,  even  if  it  be  somewhat  consistent,  may  escape  freely.  When  urine 
or  serous  accumulations  are  to  be  drawn  off,  a  smaller  canula  should  be 
selected.  The  slight  wound  made  by  the  stylet  or  canula  should  be  carefully 
closed  by  a  strip  of  adhesive  plaster.  Although  the  operation  of  aspiration 
is  made  very  simple  by  the  improved  instruments  now  in  use,  yet  certain 
precautions  must  be  observed  to  render  its  performance  free  from  danger. 
The  operator  should  make  himself  perfectly  familiar  with  the  relation  that 
the  bloodvessels  and  nerves,  or  other  important  organs,  bear  to  the  cavity 
containing  the  fluid,  before  he  proceeds  to  introduce  the  canula  or  needle. 
Without  this  special  knowledge,  he  is  liable,  of  course,  to  do  his  patient  an 
irreparable  injury. 

Surgical  Uses  of  Electricity.1 

The  surgical  uses  of  electricity  consist  chiefly  in  the  various  applications 
of  the  operations  known  as  electrolysis  and  electro-  or  galvano-cautcry.    Electro- 

1  The  writer  takes  pleasure  in  acknowledging  his  indebtedness  to  Dr.  Charles  K.  Mills. 
Lecturer  on  Electro-Therapeutics  in  the  University  of  Pennsylvania,  for  valuable  assistance  iu 
preparing  this  section. 


522 


MINOR    SURGERY. 


lysis  means  chemical  decomposition  by  electricity,  and  the  term  is  applied  in 
surgery  chiefly  to  the  decomposition  by  means  of  this  agent  of  tumors,  exu- 
dations, or  other  morbid  products.  Electro-  or  galvano-cautery  is  the  process 
of  cauterizing  or  burning  tissues  by  means  of  a  wire,  or  other  metallic  instru- 
ment, which  has  been  heated  hy  electricity.  Strictly  speaking,  galvano- 
cautery  is  not  an  electrical  operation;  electricity  is  simply  used  to  heat  the 
instrument  with  which  the  cauterization  is  performed.  The  terms  electro- 
puncture  and  galvano-puncture  refer  to  electrolysis,  to  the  plunging  of  needles 
into  a  part  through  which  an  electric  current  is  made  to  pass. 

Electrolysis. — For  electrolysis,  a  suitable  battery,  and  needle  electrodes  of 
special  shapes,  are  required.  The  apparatus  generally  preferred  is  a  galvanic 
or  continuous-current  battery  of  a  considerable  number  of  cells  of  medium 
size;  some  form  of  zinc-carbon  battery  of  thirty  or  more  cells.  The  fluid  that 
will  probably  be  found  most  serviceable  is  the  well-known  solution  of  potas- 
sium bichromate.  Almost  any  of  the  constant  batteries,  however,  which  are 
employed  in  the  treatment  of  diseases  of  the  nervous  and  muscular  systems,  can 
be  made  use  of  in  this  operation.     Fig.  92    represents  an  improved,  portable, 

Fig.  92. 


Constant  galvanic  l>attery. 

constant  galvanic  battery,  manufactured  by  Messrs.  Flemming  and  Talbot,  of 
Philadelphia.  This  battery  contains  thirty  cells ;  others  ranging  as  high  as 
sixty  cells  are  made.  Electrolysis  lias  been  resorted  to  with  more  or  less  suc- 
cess in  the  treatment  of  aneurism,  tumors,  and  conditions  dependent  upon  old 
inflammatory  deposits  The  forms  of  tumor  that  have  been  treated  electri- 
cally are  naevi,  goitres,  polypi,  cysts,  hydatids,  fibroids,  cpitheliomata,  scir- 
rhous cancers,  etc. 


SURGICAL   USES    OF   ELECTRICITY. 


523 


In  the  treatment  of  aneurism,  two  methods  are  employed.  One  method  is 
to  insert  the  needle,  connected  with  only  one  of  the  poles  of  the  battery,  into 
the  sac,  the  other  rheophore  being  applied  to  the  surface  of  the  body.  In  the 
second  and  better  method,  two  tine,  sharp  needles,  carefully  insulated  nearly 
to  their  extremities,  and  connected  with  the  conducting  cords  from  both  poles 
of  the  battery,  are  introduced  into  the  aneurisnial  sac.  At  first  a  weak  cur- 
rent is  allowed  to  pass,  its  strength  being  gradually  and  cautiously  increased 
as  the  operation  'advances.  The  operation  should  be  performed  slowly,  as 
clots  that  are  rapidly  produced  are  liable  to  be  washed  away  by  the  blood 
current.  At  the  expiration  of  a  period  varying  from  half  an  hour  to  an  hour, 
the  needles  are  to  be  removed,  and  the  punctures  closed  by  small  compresses 
of  lint  secured  by  plaster  or  collodion.  In  some  cases  it  will  be  found  neces- 
sary, in  consequence  of  the  timidity  of  the  patient,  or  of  pain,  to  resort  to 
anaesthesia  either  local  or  general. 

In  treating  tumors  of  any  kind  by  electrolysis,  the  methods  are  practieally 
the  same.  As  in  the  case  of  aneurism,  needles  either  from  one  or  from  both 
poles  of  the  battery  are  introduced  directly  into  the  tumor,  in  the  same  way 
that  a  hypodermic  needle  would  be  inserted.  The  cells  of  carcinomata  are  said 
to  yield  sooner  to  electrolysis  than  other  cells,  just  as  one  body  may  decompi  >se 
more  readily  than  another.  Some  electro-therapeutists,  the  two  Brans,  for 
example,  consider  that  the  destructive  action  of  the  current  is  strictly  and 
wholly  due  to  the  action  of  the  alkali  developed  at  the  negative,  and  the  acid 
at  the  positive  pole.  In  addition  to  its  uses  in  cases  of  aneurism  and  tumors, 
it  is  claimed  by  electro-therapeutists  that  electrolysis  is  serviceable  in  the 
treatment  of  hydrocele,  stricture  of  the  urethra,  opacities  of  the  cornea,  cata- 
ract, inflammatory  thickenings  in  and  about  the  ear,  etc. 

Galvano-Cautery. — Galvano-cautery  batteries  are  made  with  plates  or  ele- 
ments of  a  large  size,  but  comparatively  few  in  number,  and  placed  close  to 
one  another.  In  this  way,  " internal  resistance"  as  the  electrician  would  say, 
is  reduced,  and  a  current  is  obtained  which  will  keep  a  metallic  electrode  at 
a  white  heat.  There  are  many  varieties  of  the 
galvano-cautery  battery,  but  perhaps  the  most 
compact  and  generally  useful  apparatus  is  the 
Byrne  Cautery  Battery,  an  invention  of  Dr.  John 
Byrne,  of  Brooklyn,  X.  Y.  Figs.  93  and  94 
represent  the  battery  and  the  necessary  appliances, 
such  as  handles,  ecraseurs,  knives,  moxa,  scoops, 
etc.  The  galvano-cautery  may  be  employed  in 
nearly  all  operations  in  which  the  actual  or  potential 
cautery,  or  the  ecraseur,  are  employed.  By  its  aid 
morbid  growths  and  diseased  parts  can  be  removed 
with  greater  expedition,  and  with  less  risk  of  con- 
secutive hemorrhage,  than  with  the  ordinary,  ecra- 
seur. When  resorted  to  as  a  means  of  applying  the 
cautery  in  cavities,  its.  action  can  be  more  accu- 
rately localized  than  that  of  the  ordinary  methods 
of  cauterization;  for  which  reason,  many  gynae- 
cologists prefer  this  apparatus  to  all  others  in  their 
operations  on  the  cervix  uteri  and  in  the  cavity  of 
the  womb. 

The  success  attending  the  use  of  the  galvano- 
cautery  is  mainly  dependent  on  the  degree  of  tem- 
perature employed.     Experience  has  demonstrated  that  a  dull  red  heat  pro- 
duces the  best  results,  and  hence  this  temperature  should  be  continuously 


Fig.  93. 


Byrne's  cautery  battery. 


524 


MINOR   SURGERY. 


maintained  during  the  period  of  actual  cauterization.     The  main  advantage 
of  a  galvano-cautery,  is  that  the  wire  or  other  electrode  can  be  accurately  ad- 


L 


iCOSOQ 


agjySflfSQ' 


Electrodes  for  galvano-cautery.     1,  £craReur  -with  -wire  loop  ;  2,  Handle  without  ecraseur  attachment ;  3,  Cautery 
knife ;  4,  Universal  hard-rubber  handle  ,  5,  Platinum  moxas  and  scoops  ,  6,  Porcelain  moxas. 

justed  in  the  required  position  while  cold,  and  then  quickly  heated.  The 
galvanic  ecraseur  of  Middeldorpf  consists  of  a  coil  of  platinum  wire  which,  by 
its  attachments  to  a  rod  and  a  screw,  can  be  shortened  as  it  burns  its  way 
through  the  tissues  around  which  it  is  placed.  Before  applying  the  coil 
around  a  diseased  mass,  as  a  cancerous  nodule  of  the  tongue,  it  is  highly  im- 
portant that  the  morbid  structure  should  be  isolated  from  the  healthy  tissues. 
This  is  best  accomplished  by  long  pins,  ivory  pegs,  or  curved  needles  in  han- 
dles, passed  through  the  healthy  part  in  different  directions.  The  coil  is  then 
placed  around  the  part,  behind  the  pins,  and,  as  it  burns  its  way  through,  the 
direction  of  the  section  will  be  determined  by  that  of  the  pins.  [Faure's  in- 
genious "secondary  battery,"  by  which  the  galvanic  current  can  be,  as  it  were, 
stored  away  for  future  use,  will  probably  add  very  much  to  the  practical 
advantages  of  this  mode  of  applying  electricity.1] 

[i  See  British  Medical  Journal,  June  11,  1881,  pago  914.] 


MASSAGE. 


525 


Galvanization  and  Faradization  often  prove  of  service  in  the  various 
neuralgic  and  paralytic  conditions  which  accompany  or  follow  surgical  affec- 
tions. In  some  forms  of  spinal  curvature,  and 
of  club-foot,  the  muscles  can  be  advantageously 
faradized.  Sprains,  muscle-strains,  and  some 
forms  of  synovitis,  can  also  with  advantage  be 
treated  by  local  faradization  or  galvanization. 
Fig.  95  represents  one  of  the  best  forms  of 
faradic  battery. 


Massage. 

Under  the  general  term  of  massage,  Dr.  "W. 
Wagner,  of  Friedburg,1  includes  four  different 
manipulations,  viz.,  (1)  stroking  {effleurage)\ 
(2)  kneading  {■petrissage)',  (3)  tapping  or  per- 
cussion (tapotement) ;  and  (4)  passive  and  active 
motion.  To  these  varieties  may  be  added  an- 
other form  of  massage,  quite  extensively  used  Faradic  battery. 
in  this  country,  which  consists  in  pinching  up 

the  integuments  and  muscles,  the  latter  singly  or  in  groups,  and  rolling  them 
gently  between  the  thumb  and  fingers.  In  the  larger  cities  this  treatment  is 
generally  intrusted  to  assistants  called  rubbers,  manipulators,  or  masseurs, 
who,  being  specially  trained  to  the  art,  soon  gain  great  dexterity  in  its  appli- 
cation. Preliminary  to  the  application  of  massage,  the  part  to  be  operated 
upon  should  be  anointed  with  cocoa-oil  or  vaseline.  If  there  be  a  heavy 
growth  of  hair  on  the  part,  this  should  be  carefully  shaved,  as  otherwise  irri- 
tation of  the  follicles  and  the  development  of  boils  may  be  the  consequences  of 
the  rubbing. 

Stroking  {Effleurage)  consists  in  gently  smoothing  or  rubbing  the  surface 
of  a  part  with  the  palm  of  the  hand  from  the  periphery ;  distended  veins  and 
lymphatics  are  thus  emptied,  and  liquid  transudation  removed  from  the  tis- 
sues. In  the  early  stages  of  inflammation,  this  manipulation  is  first  applied 
above  the  seat  of  disease,  in  order  to  afford  more  space  for  the  returning  cur- 
rents. By  degrees  the  inflamed  part  is  approached,  and,  when  reached^  firm 
but  gentle  pressure  is  made  on  it,  thus  forcing  the  fluids  inwards,  and  pro- 
moting the  absorption  of  exudations  if  they  have  already  occurred.  With  a 
diminution  in  the  contents  of  the  vessels,  there  is  a  proportionate  subsidence 
of  all  the  local  phenomena  of  inflammation. 

Kneading  {Petrissage)  is  a  form  of  massage,  applied  by  rubbing  a  part  cir- 
cularly with  the  extremities  of  the  fingers  or  thumb,  or  the  palm  of  the  hand, 
and  is  indicated  in  cases  of  inflammatory  transudations,  and  in  those  of 
ecchymosis  into  the  subcutaneous  cellular  tissue.  Kneading  may  with  ad- 
vantage be  combined  with  stroking,  whenever  it  is  desirable  not  only  to  break 
up  exudation,  but  likewise  to  hasten  the  removal  of  the  resulting  detritus 
from  the  tissues.  The  amount  of  pressure  to  be  used  in  applying  this  variety 
of  massage  must  be  determined  by  the  nature  and  the  seat  of  the  material  to 
be  gotten  rid  of,  and  by  the  sensitiveness  of  the  patient.  A  vigorous  appli- 
cation of  this  manipulation  is  more  apt  to  be  tolerated  in  cases  of  partially 


•  Berliner  klinische  Wochenschrift,  Nov.  6  und  13,  1876. 
nal,  May  17.  1877. 


Boston  Medical  and  Surgical  Jour- 


526  MINOR   SURGERY. 

organized  inflammatory  products,  especially  when  they  are  deep  seated,  than 
in  those  of  extravasation  or  serous  exudation. 

Percussion  (Tapotement)  is  another  form  of  massage,  which  consists  in  tap- 
ping the  surface  of  an  aifected  part  either  with  the  tips  of  the  fingers  held  in 
a  row,  a  small  hammer,  or  the  ulnar  border  of  the  hand.  Sometimes  the 
palm  of  the  hand  is  brought  into  requisition,  when  a  considerable  surface  of 
the  trunk,  as  the  loins,  is  the  subject  of  treatment.  It  is  claimed  by  some 
authors  that  percussion  will  cure,  or  ameliorate,  some  forms  of  neuralgia  and 
of  peripheral  paralysis,  by  promoting  the  absorption  of  exudation  from  around 
the  affected  nerves.  The  beneficial  effects  of  percussion  in  these  cases  will 
be  greatly  increased  if  the  nerves  be  stretched  and  the  overlying  integuments 
kneaded. 

Passive  and  Active  Motion,  in  conjunction  with  the  manipulations 
already  considered,  are  found  of  special  service  in  getting  rid  of  those  trouble- 
some conditions  so  often  following  sprains,  dislocations,  fractures,  and  other 
affections  that  require  immobilization  of  the  affected  limb  as  an  essential 
feature  of  the  early  treatment.  While  the  limb  is  subjected  to  stroking, 
kneading,  etc.,  passive  motion  of  the  joints  should  at  first  be  made  by  the 
manipulator,  and,  as  soon  as  practicable,  the  patient  himself  should  be  encour- 
aged to  employ  active  motion.  The  persistent  employment  of  passive  and 
active  motion  will  often  restore  the  functions  of  a  stiff  joint  sooner,  and  Avith 
less  suffering  to  the  patient,  than  the  forcible  breaking  up  of  adhesions  under 
anaesthesia. 

In  the  treatment  of  old  sprains,  and  of  the  later  stages  of  fracture  of  the 
extremities,  where  the  muscles  have  lost  tone  and  become  flabby  in  conse- 
quence of  disease,  Dr.  Douglas  Graham1  suggests  the  employment  of  what  he 
calls  ado-passive  motion,  as  a  means  of  restoring  the  strength  of  those  mus- 
cles, and  of  giving  the  patient  confidence  to  use  them.  This  manipulation 
consists  in  "alternately  resisting  flexion  and  extension,  while  keeping  the 
resistance  less  than  the  strength  of  the  limb,  so  that  the  patient  may  not  re- 
cognize his  weakness  there." 

Muscle-beating. — C.  Klemm,  Manager  of  the  Gymnastic  Institution  in 
Riga,2  has  suggested  a  form  of  massage  which  he  terms  musde-beatiwg.  The 
instrument  that  he  uses  in  practising  this  treatment  is  called  a  muscle-beater, 
and  consists  of  three  elastic  tubes  fastened  together  near  a  handle  to  which 
they  are  attached.  The  circumference  of  each  tube  is  about  that  of  a  finger; 
the  length  and  the  thickness  of  the  material  of  which  the  tubes  are  made 
vary  according  to  the  different  purposes  for  which  the  instrument  is  em- 
ployed— hence  muscle-beaters  of  different  sizes  are  needed.  Muscle-beating 
is  not  to  be  made  on  a  naked  surface,  except  in  case  of  the  head  or  the  hand; 
the  part  should  be  protected  by  a  thin  covering  of  some  kind.  The  duration 
of  a  "seance"  should  be  determined  by  the  impressionability  of  the  part;  it 
is  always  well  to  suspend  the  operation  as  soon  as  a  sensation  of  moderate 
burning,  or  an  increase  of  the  surface  temperature,  is  felt  by  the  patient.  The 
application  of  this  manipulation  should  be  interrupted  by  slight  pauses  of  a 
minute  or  two,  in  order  that  excessive  irritation  of  the  skin  maybe  avoided. 

Among  the  many  diseased  or  abnormal  conditions  for  which  muscle-beating 
is  recommended  by  ('.  Klemm,  are  coldness  of  the  extremities,  muscular  ataxy, 
stiffness  of  the  joints   consequent  upon  sprains,  dislocations,  rheumatism, 

1  Boston  Medical  and  Surgical  Journal,  vol.  xix.  p.  578,  1877. 

*  Muscle-beating,  or  Active  and  Passive  Home  Gymnastics.     New  York,  1S79. 


USE    OF    THE    THERMOMETER   IX   SURGERY.  527 

lateral  curvatures  of  the  spine,  etc.  With  a  little  experience  in  the  use  of 
the  muscle-beater,  an  individual  may  apply  the  treatment  to  his  own  person, 
and  thus  dispense  with  the  services  of  a  professional  masseur.  Many  of  the 
benefits  arising  from  active  exercise  will  be  experienced  by  an  individual 
who  can  practise  muscle-beating  in  his  own  case  ;  hence  it  is  a  good  plan, 
when  practicable,  for  the  physician  to  instruct  his  patient  in  the  method  of 
employing  this  manipulation. 

Massage  should  not  be  applied  just  before  or  immediately  after  eating ;  an 
hour  midway  between  breakfast  and  dinner,  or  lunch,  seems  the  most  suita- 
ble. If  two  sittings  a  day  are  deemed  necessary,  the  second  should  be  at  a 
corresponding  period  between  the  midday  and  evening  meals.  The  treatment 
should  be  applied  at  least  once  a  day ;  some  cases  are  undoubtedly  benefited 
by  two  applications  in  the  twenty-four  hours.  The  duration  of  a  sitting  will 
depend  on  the  circumstances  of  each  case ;  an  hour  may  be  considered  the 
maximum. 


Use  of  the  Thermometer  in  Surgery. 

For  clinical  observations,  two  thermometer  scales  are  in  common  use,  the 
Centigrade  and  Fahrenheit;  the  former  is  used  in  almost  all  countries  except 
England  and  America,  where  the  latter  is  preferred.    As  these  thermometers 
are  specially  designed  for  detecting  abnormal  variations  of  bodily 
temperature,  their  scale  has  a  limited  range,  usually  a  few  degrees      Fig.  96. 
above  and  below  the  normal  temperature,  which  amounts  to  98|°  /T\ 

F.  =  36°  C.  The  degrees,  and  their  subdivisions  into  fifths  or 
tenths,  are  either  etched  on  the  stem  of  the  instrument  or  marked 
on  a  plate  of  ivory  that  is  attached  to  the  stem.  There  are  many 
varieties  of  thermometers  in  use,  but  the  straight,  self-registering, 
clinical  thermometer  (Fig.  96)  has  been  proved  by  experience  to 
be  the  best.  In  this  variety,  the  upper  part  of  the  column  of 
mercury  is  separated  by  a  small  bubble  of  air.  This  detached  piece 
of  mercury  is  called  the  index,  from  the  fact  that  when  it  is 
pushed  up  by  the  main  column,  it  remains  in  position,  and  indi- 
cates the  degree  of  temperature.  Thermometers  are  now  made 
with  a  "  convex  face"  between  the  etched  lines  and  the  figures  of 
the  scale,  this  serving  to  magnify  the  column  of  mercury,  and 
thus  enabling  the  observer  to  note  quickly  the  position  of  the 
index.  Before  using  this  instrument,  the  index  must  be  shaken 
down  to  a  point  two  or  three  degrees  below  the  normal  tempera- 
ture. This  is  done  by  holding  the  thermometer  in  the  hand  with 
the  bulb  downwards,  and  either  striking  the  ulnar  border  of  the 
hand  which  grasps  the  instrument  forcibly  against  the  radial 
border  of  the  other  hand,  or  raising  the  hand  from  the  body  and 
bringing  it  down  with  a  quick  motion  or  jerk.  There  should  be 
a  slight  constriction  between  the  stem  and  the  bulb  of  the  instru- 
ment, to  prevent  the  index  from  passing  into  the  bulb  when  it  is 
shaken  down. 

As  accuracy  of  registration  is  of  prime  importance  in  the  use 
of  a  thermometer,  every  instrument  ought  to  be  compared  with 
some  recognized  standard.  English  thermometers  are  compared 
with  the  standard  at  Kew  Observatory,  and'  if  any  variation  be 
detected,  no  matter  how  small,  it  is  noted  in  a  certificate  which  cnnicTi  ther- 
accompanies  the  instrument.    A  like  arrangement  is  provided  for       mometer. 


528 


MINOR   SURGERY. 


testing  American  thermometers,  at  the  observatory  at  Cambridge,  Mass. 
Should  it  not  be  convenient  to  make  the  comparison  with  some  standard, 
the  variation  may  be  approximately  determined  by  taking  the  temperature 
of  a  healthy  person.  One  thermometer  should  not  be  substituted  for  another 
in  making  a  series  of  observations  in  the  same  case. 

The  temperature  may  be  taken  in  the  axilla,  the  mouth,  the  vagina,  or  the 
rectum.  For  obvious  reasons,  the  axilla  is  usually  selected,  although  the 
mouth  is  equally  convenient  for  taking  the  temperature.  The  rectum  or  the 
vagina  should  never  be  chosen  for  taking  a  therniometric  observation  when 
the  other  regions  are  accessible.  Before  taking  the  temperature  in  the 
axilla,  all  clothing  encroaching  upon  this  space  should  be  removed,  and  any 
moisture  that  there  may  be  on  the  surface  wiped  off.  To  raise  the  tempera- 
ture of  the  axillary  space  to  that  of  the  body,  the  arm  should  be  kept  close 
to  the  side  of  the  chest  for  two  or  three  minutes ;  if  this  be  done  beforehand, 
the  instrument  will  not  have  to  be  left  in  place  as  long  as  it  would  otherwise. 
The  bulb  of  the  thermometer  is  then  put  in  the  centre  of  the  axilla,  well 
under  its  anterior  margin,  and  the  arm  brought  to  the  side  of  the  thorax 
with  the  forearm  across  the  body.  The  patient  should  keep  his  arm  and 
forearm  in  this  position  for  at  least  five  minutes.  In  the  case  of  an  infant  or 
a  very  feeble  patient,  the  arm  should  be  held  pressed  against  the  body.  If 
the  thermometer  be  self-registering,  it  may  be  removed  and  the  position  of 
the  index  noted,  at  the  expiration  of  the  time  mentioned ;  otherwise  the 
instrument  must  be  examined  before  it  is  taken  out  of  the  axilla. 

If  the  thermometer  be  introduced  into  the  mouth,  the  patient  should  be 
directed  to  keep  his  lips  tightly  closed  around  the  stem  of  the  instrument, 
and  to  breathe  through  his  nose.  "Whenever  a  series  of  thermometrie 
observations  is  made  in  a  case  of  disease,  it  will  be  found  convenient  to  use, 
for  noting  the  daily  variation,  some  form  of  register  or  chart 
which  may  be  kept  for  reference. 

The  fact  that  there  is  a  normal,  diurnal  fluctuation  in  the  tem- 
perature of  a  healthy  person,  which  is  not  influenced  by  external 
circumstances,  must  not  be  lost  sight  of  whenever  an  attempt  is 
made  to  determine  the  effects  of  disease  in  causing  variations  of 
the  bodily  heat.  In  a  state  of  health,  the  temperature  steadily 
rises  from  morning  till  towards  evening,  after  which  it  gradually 
sinks  again  till  morning.  There  is  a  difference  of  from  1°  to  2° 
F.  between  the  morning  minimum  and  the  evening  maximum. 
Exercise  and  the  ingestion  of  food  have  the  effect  of  raising  the 
temperature  slightly,  but  rarely  more  than  one  degree.  The  tem- 
perature in  middle  age  is  a  little  lower  than  in  childhood,  or  in 
the  later  periods  of  life.  ."Whenever  it  is  essential  to  ascertain 
the  amount  of  daily  exacerbations  of  temperature,  two  observa- 
tions should  be  made :  one  in  the  morning  between  6  and  8  A.  M. ; 
the  other  in  the  evening  between  4  and  6  F.  M. 

In  practising  surface-thermometry,  instruments  having  bulbs  of 
discoid  shape,  or  drawn  out  in  the  form  of  a  spiral  or  coil,  are 
generally  employed.  In  Fig.  97  is  represented  a  convenient 
form  of  surface-thermometer ;  this  instrument  has  a  stem  and 
graduated  scale  like  the  ordinary  axillary  thermometer,  but  its 
bull)  is  a  glass  coil,  surrounded  by  a  band  of  hard  rubber  which 
protects  it  from  injury  and  prevents  loss  of  heat.  In  some  local- 
ities, as  in  the  intercostal  spaces  and  the  vicinity  of  many  joints, 
the  ordinary  axillary  thermometer,  owing  to  the  shape  of  its  bulb, 
can  be  used  to  better  advantage  than  any  of  the  surface-thermo- 
meters.    To  determine  accurately  the  amount  of  variation  in  the 


Fig.  97. 


Surface  ther- 


momoter. 


USE    OF    THE    SPHYGMOGRAPH.  529 

surface  temperature  of  a  part,  it  is  essential  that  the  temperature  of  the  cor- 
responding part  of  the  opposite  side,  and  the  general  temperature  of  the  body, 
should  be  taken  at  the  same  time. 


Use  of  the  Sphygmograph. 

By  means  of  the  sphygmograph,  the  pulsations  of  an  artery  may  be  auto- 
matically registered.  Although  the  idea  of  making  an  artery  record  its  own 
pulsations  is  not  a  recent  one,  yet  the  practical  realization  of  this  conception 
of  Galileo  dates  from  the  invention  of  the  sphygmograph  by  Vierordt  and 
Marey. 

Two  forms  of  this  instrument  are  in  use  at  the  present  time :  M.  Marey's, 
modified  by  Dr.  Mahomed,  and  Dr.  E.  A.  Pond's ;  the  former  in  England 
and  on  the  continent  of  Europe  ;  the  latter  principally  in  America.  Marey's 
sphygmograph  consists  of  a  brass  framework  to  which  are  attached  an 
arrangement  of  levers  designed  to  be  acted  upon  by  the  pulsating  artery,  and 
a  clockwork  which  propels  a  slide  carrying  a  piece  of  paper  or  mica  on  which 
the  pulsations  are  registered.  To  regulate  and  measure  the  amount  of  pres- 
sure made  on  the  artery  by  the  mainspring,  Dr.  Mahomed  has  had  attached 
to  the  side  of  the  framework  an  eccentric  wheel,  which  acts  upon  the  main- 
spring, and  is  worked  by  a  thumb-screw.  The  degree  of  pressure  exerted 
upon  the  mainspring  by  the  eccentric  is  indicated  on  a  dial-plate.  The 
pressure  is  measured  in  troy  ounces,  from  one  to  eighteen;  the  amount  of 
pressure  employed  in  taking  a  tracing  should  always  be  recorded  on  the  slip 
with  the  latter.  Preparatory  to  taking  a  tracing,  the  forearm  of  the  patient 
is  laid,  with  the  palmar  surface  upwards,  on  a  splint  or  some  other  convenient 
support,  as  on  a  double-inclined  pad  with  an  angle  of  about  135°,  with  the 
hand  bent  slightly  backwards.  The  sphygmograph  is  placed  on  the  forearm 
with  the  ivory  pad  at  the  free  extremity  of  the  mainspring,  directly  on  that 
portion  of  the  radial  artery  which  lies  to  the  inner  side  of  the  styloid  process 
of  the  radius.  When  the  instrument  is  properly  adjusted,  it  is  secured  by 
straps  buckled  around  the  limb.  In  order  that  a  satisfactory  tracing  may  be 
obtained,  the  hand  must  not  be  too  much  extended,  nor,  on  the  other  hand, 
should  it  be  tightly  closed.  In  the  former  position,  the  pulsations  of  the 
artery  are  liable  to  be  interfered  with  by  the  vessel  being  stretched  over  the 
surface  of  the  bone ;  in  the  latter,  the  tendons  adjacent  to  the  artery  are 
made  tense,  and  rise  above  its  level,  thus  preventing  the  pad  from  coming  in 
contact  with  the  vessel.  With  the  instrument  properly  adjusted,  it  is  neces- 
sary to  determine  the  amount  of  compression  that  must  be  made  by  the  pad 
on  the  artery,  in  order  to  give  the  greatest  range  of  movement  of  the  record- 
ing lever ;  this  may  be  done  by  means  of  the  graduated  thumb-screw. 

The  paper  on  which  the  tracing  is  to  be  made  should  be  enamelled  on  both 
sides,  and  smoked  on  one.  It  may  be  smoked  by  holding  it  over  the  flame 
of  a  small  piece  of  burning  camphor,  or  over  a  little  mass  of  ignited  cotton 
saturated  with  olive  oil,  or  over  a  smoking  paraffine  lamp.  Slips  of  mica 
may  be  smoked  in  the  same  way.  A  slip  thus  prepared  is  placed  on  the 
travelling  slide,  with  the  point  of  the  recording  lever  in  contact  with  the 
blackened  surface.  By  touching  a  button  connected  with  the  clockwork, 
the  latter  is  set  in  motion,  and  the  slide  carrying  the  slip  is  steadily  moved 
along. 

The  sphygmograph  invented  by  Dr.  E.  A.  Pond,  of  Vermont,  has  many 
advantages  which  recommend  it  as  superior  to  all  other  forms  of  the  instru- 
ment.    It  is  compact  in  size  and  very  easily  adjusted  to  the  principal  arterial 
vol.  i. — 34 


530 


MINOR   SURGERY. 


Fig.  98. 


trunks  of  the  extremities,  and  furnishes  tracings  of  a  delicate  and  reliable 
character  in  a  very  short  time.  The  improved  form  of  Dr.  Pond's  sphygmo- 
graph  does  not  require  a  splint  or  other  support  for  the  part  to  which  the 
instrument  may  be  applied.  The  pulsations  of  an  artery  are  communicated 
to  the  expanded  extremity  of  a  vertical  lever,  inclosed  in  a  tube  that  is 
closed  below  by  a  diaphragm  of  thin  rubber.  This  lever  is  connected  with  a 
system  of  levers  which  serve  to  move  a  pendulum-jointed  needle  which 
records  the  arterial  pulsations  on  a  slip.  A  watch-movement  attached  to 
the  vertical  tube  by  an  upright  moves  the  tracing-slip  on  a  fixed  horizontal 

slide.  A  pressure-gauge,  graduated  from 
one  to  sixteen  ounces,  is  attached  to  the 
tube  containing  the  vertical  lever,  and 
indicates  the  amount  of  pressure  made  on 
an  artery  when  a  tracing  is  being  taken. 
(Fig.  98.)  A  slip  of  enamelled  paper  or 
mica,  prepared  as  has  already  been  de- 
scribed for  receiving  a  tracing,  is  secured 
on  the  slide  by  setting  free  the  watch- 
movement  ;  when  the  slip  has  been  carried 
along  about  a  quarter  of  an  inch,  the 
watch-movement  is  stopped  till  the  sphyg- 
mograph  is  adjusted.  The  operator  then 
places  the  instrument  over  the  artery 
(usually  the  radial,  just  within  the  styloid 
process  of  the  radius),  with  the  button- 
like extremity  of  the  vertical  lever  im- 
pinging upon  the  vessel,  and  holds  it 
steadily  in  this  position  while  the  tracing 
is  being  taken.  The  amount  of  com- 
pression that  will  give  the  maximum 
movement  to  the  needle  on  the  slip  may 
be  ascertained  by  observing  the  pressure- 
gauge  as  the  pressure  on  the  artery  is 
varied  ;  this  degree  of  compression  should 
be  maintained  during  the  operation.  With 
the  instrument  properly  adjusted,  and  the  tracing-slip  in  position,  the  watch- 
movement  is  to  be  liberated — to  be  again  stopped  when  the  slip  has  been 
propelled  over  the  platform. 

Should  it  be  desirable,  sphygmographic  tracings  can  be  readily  preserved  by 
varnishing  them.  To  make  them  of  service  for  future  reference,  the  name 
of  the  patient,  the  date  of  the  observation,  and  the  amount  of  pressure  made 
on  the  artery,  should  be  inscribed  on  the  blackened  surface  of  each  slip  by 
means  of  some  sharp-pointed  instrument,  as  a  needle  or  pin.  The  varnish 
recommended  by  Dr.  A.  E.  Sansom  is  composed  of  gum  benzoin,  one  ounce, 
and  methylated'  spirit,  six  ounces.  Dr.  Pond  prefers  one  consisting  of 
alcohol,  one  pint ;  gum  sandarac,  three  ounces;  and  castor  oil,  half  an  ounce. 
The  slips,  utter  having  been  inscribed,  are  carefully  dipped  in  the  varnish, 
and  allowed  to  dry. 


Pond's  sphygmograph. 


PLASTIC  SURGERY. 

BY 

CHRISTOPHER  JOHNSTON,  M.D., 

EMERITUS  PROFESSOR  OF  SURGERY  IN  THE  UNIVERSITY  OF  MARYLAND,   BALTIMORE. 


The  Surgical  Art  Formative  (ttxdaanv  to  form)  boasts  of  a  high  antiquity, 
and  was  resorted  to  in  remote  times,  as  at  present,  to  repair,  remedy,  or 
conceal  the  ravages  and  disfigurements  of  disease,  as  well  as  to  lessen  the 
deformities  produced  by  the  execution  of  judicial  decrees,  by  natural  defects, 
or  by  the  accidents  of  personal  or  general  conflict.  That  branch  of  this 
department  of  surgery  which  has  for  its  object  the  restoration  of  noses,  very 
probably  antedated  the  other  branches,  as  the  records  of  Indian  and  Egyptian 
surgical  art  seem  to  indicate;  but  while  the  subdivisions  of  the  art  multiply, 
as  various  organs  or  parts  are  concerned,  the  principles  governing  all  plastic 
proceedings  remain  the  same.  The  synonyms  of  this  department  of  surgery 
are  numerous;  thus,  Chirurgica  Plastica;  Morioplastice,  from  fioptov  "a  part,'"' 
and  nxdanxoi  "forming;"  Transplantatio;  Chirurgia  Anaplastica  and  Chirurgia 
Autoplastica — names  preferred  by  Velpeau  and  Blandin,  and  derived  from 
the  Greek,  the  one  from  dvd  "again,"  and  nxdaanv  "to  form,"  that  is,  to  fashion 
anew;  the  other  from  airoj  "one's  self,"  and  mdaotw  "to  form,"  to  form  of,  or 
out  of,  one's  self,  or  "self  creation"  (Gross)— whence  the  words  Anaplasty, 
Autoplasty;  and  finally  Plastic  Surgery,  or  that  province  of  surgery  which 
is  distinctively  formative. 

Among  the  foregoing  appellations  I  revert  to  Transplantatio,  which 
signifies  absolute  removal  from  one  part  and  implantation  into  another,  to 
point  out  that  such  transplantation  of  larger  portions  of  the  body  has  been 
designedly  accomplished,  or  an  accidentally  ablated  part  successfully  reapplied, 
or  blood  transfused — all  instances  of  total  separation  before  adjustment,  or,  in 
the  case  of  the  blood,  of  perfect  abstraction  and  introduction  into  the  circu- 
latory system  of  another  individual ;  and  that  the  same  end  has  been  medi- 
ately effected  as  in  Roux's  operation,  that  of  "Autoplasty  by  successive 
migrations  of  the  flap."  And  I  would  associate  with  these  instances  of 
union  of  larger  surfaces,  or  multitudes  of  germs,  the  modern  operation  of 
Reverdin,  known  as  skin  grafting,  by  which  extremely  small  portions  of  in- 
tegument, and  even  epithelial  elements  scooped  from  the  rete,  after  being 
totally  separated,  are  implanted  or  " grafted"  upon  the  surface  of  tardily  heal- 
ing ulcers,  as  of  burns.  Adhesion  soon  occurs,  and  is  followed  by  prolifera- 
tion around  the  transplanted  germs,  whether  these  have  been  derived  from 
the  subject  himself,  or  from  another  person;  whether  they  are  pigmented  or 
otherwise.  The  transplantation  of  the  spur  of  the  cock,  from  the  leg  to  the 
comb,  is  a  familiar  example  of  this  mode  of  procedure,  as  is  also  the  trans- 
lated flap  of  Roux;  but  in  these  instances,  vitalized  adherence  terminates  the 
process;  whereas,  in  the  case  of  skin  grafting,  as  practised  by  Reverdin  and 

(531) 


532  PLASTIC   SURGERY. 

others,  the  stranger  germs  are  extremely  few  in  each  grafted  particle,  but 
they  form  the  centres  or  foci  of  a  cell-formation  which  gradually  but  surely 
spreads  and  closes  over  the  reluctant  surface. 


History  of  Plastic  Surgery. 

Though  we  cannot  fix  the  exact  period  at  which  plastic  surgery  was  first 
practised,  yet  we  may  be  sure  that  it  must  have  followed  with  a  kindly  hand 
the  barbaric  use  of  power  and  the  cruel  resentment  which  were  displayed  at 
an  early  period  of  the  world's  history,  especially  in  India,  in  the  mutilation 
of  offenders  by  the  lopping  off  of  ears  and  noses.  And  in  ancient  Egypt,  also, 
Rhinoplasty  was  known  and  practised,  as  Galen  declares,  and  as  may  readily 
be  believed  if  we  accept  as  indirectly  confirmatory,  the  Ebers  Papyrus,  "the 
Hermetic  Book  of  Medicines  of  the  Ancient  Egyptians,  in  Hieratic  Writ- 
ing," of  unknown  authorship.  And  it  is  also  interesting  to  observe  that 
in  the  "  Secret  Book  of  the  Physicians"  the  science  of  "  the  beating  of  the 
heart  and  the  knowledge  of  the  heart"  are  referred  to,  as  taught  by  the 
priestly  physician,  Nebsect.  Ebers  believes  the  Papyrus  to  have  been  a  com- 
pilation made  by  the  College  of  Priests,  at  Thebes  ;  and  assigns  the  writing  to 
the  middle  of  the  sixteenth  century,  or  more  precisely  to  the  year  1552  B.  C. 
This  date,  as  is  commonly  supposed,  was  prior  to  the  departure  of  the 
Israelites,  and,  according  to  generally  accepted  chronology,  Moses,  in  1552 
B.  C,  was  just  21  years  of  age.1  The  same  author,  Professor  Ebers,  of  Jena, 
in  an  original  work  "Ouarda,"  in  which  he  assures  the  reader  that  all  his 
statements  are  based  upon  authority,  besides  furnishing  evidence  of  the  high 
position  reached  by  Medicine  in  the  reign  of  Rameses  II.,  alludes  to  its  divi- 
sion into  twenty-one  specialties,  such  as  are  accepted  and  practised  at  the 
present  day,  and  gives  prominence  to  the  thoroughness  with  which  the  science 
and  art  were  studied  and  practised  by  the  priest-physicians  of  a  great  era  in 
Egypt's  history.  The  Roman  Hippocrates,  Celsus,  who  livid  about  one  hun- 
dred and  fifty  years  before  Galen,  in  the  reigns  of  Augustus,  Tiberius,  and 
Caligula,  speaks  of  the  restoration  of  the  ears,  the  nose,  and  the  lips,  by  the  aid 
of  the  neighboring  skin,  and  also  of  reparation  of  the  prepuce.  Galen  says  but 
little  of  the  treatment  of  mutilations,  and  this  is  copied  by  Paulus  ^gineta 
and  others  of  his  followers.  Antyllus  mentions  coloboma  and  its  repair. 
And  Malgaigne,  in  his  introduction  to  Fare's  Surgery,  refers  to  an  Italian 
family,  named  Branca,  as  conservators  of  the  art  of  restoring  noses  during 
the  middle  ages,  and  as  having  invented  new  methods. 

In  the  year  1597,  at  a  time  when  learning  received  a  new  impetus,  ap- 
peared the  very  remarkable  and  erudite  work  of  Gaspar  Taliacotius,  entitled 
"He  curtorum  chirurgia  per  insitionem,"  in  two  volumes,  published  in 
Venice.  In  this  treatise,  Tagliacozzi,  besides  describing  minutely  the  opera- 
tions for  restoring  or  repairing  multilated  lips  and  ears,  gives  special  promi- 
nence to  his  original  method  of  reproducing  noses,  in  which  the  flap  is  taken 
from  the  arm,  and  which  has  ever  since  borne  the  title  of  the  Taliacotian 
or  Italian  operation  to  distinguish  it  from  the  Indian  or  Oriental  operation, 
in  which  the  flap  is  obtained  either  from  the  forehead,  the  cheek,  or  even  the 
nor  itself.  The  Indian  operation  was  first  put  in  practice  in  London,  in 
1814,  by  Carpue,  and  afterwards  in  Germany  by  J.  F.  Dieffenbach,  who,  at 
the  end  of  the  first  third  of  the  century,  gave  great  development  to  the  sub- 
ject, t<>  which  lie  drew  attention  by  the  publication  of  his  experiences  and  of 
his  improved  methods.     Subsequently,  in  France,  Blandin,  Jobert  (de  Lam- 

1  Charles  Rice,  in  N.  Y.  Daily  Tribune,  Nov.  9,  1875. 


LESIONS   REMEDIABLE   BY   PLASTIC   SURGERY.  533 

balle),  Serres,  Roux,  Denuce  and  Verneuil ;  in  Belgium,  Burggraeve  and  Ver- 
haege;  in  Germany,  Zeiss,  Von  Amnion,  Hoffacher,  Banmgarten,  Langenbeek 
and  Schuh ;  in  England,  Liston,  Pollock  and  Spencer  Wells;  and  in  the 
United  States,  J.  M.  Warren,  Pancoast,  Mutter,  Gurdon  Buck  and  others, 
both  by  their  writings  and  practice  have  made  themselves  deservedly  emi- 
nent, and,  occupying  a  high  position,  have  placed  both  the  profession  and  the 
public  under  obligation.  In  reviewing,  however,  the  copious  bibliography  of 
plastic  surgery,  I  deem  it  not  unfair  to  give  a  well-earned  prominence  to 
American  Surgeons,  whose  ingenious  and  felicitous  operations  and  practical 
treatises  and  contributions  to  science  have  established  the  reputation  of  their 
authors  upon  an  enviable  and  enduring  basis. 


Lesions  Reimediable  by  Plastic  Surgery. 

The  term  Plastic  Surges,  says  Verneuil,  "signifies,  then,1  in  surgical  lan- 
guage, the  repair  or  restoration  of  an  organ  changed  in  form,  by  the  aid  of  a 
loan  effected  in  the  patient  himself,  and  made  at  the  expense  of  neighboring 
or  distant  healthful  parts."  "It  remedies  deformities  of  deficiency  or  excess 
by  operations  of  anaplasty  by  autoplasty,  which,  term  ought  to  be  restricted  to 
cases  characterized  by  a  deficiency  of  substance  as  a  lesion,  and  by  an  organic 
borrowing  from  the  same  subject  as  an  operation.  And  this  double  character 
serves  (1)  to  establish  differences  between  the  method  in  question  and  the 
other  anaplastic  methods,  and  (2)  to  distinguish  autoplasty,  properly  so  called, 
from  heteroplasty,  which  borrows  substance  from  a  stranger  organism,  and 
from  prothesis,  which  replaces  lost  parts  with  artificial  ones  made  out  of 
inorganic  materials." 

It  is  evident  that  the  occasion  for  the  operations  of  plastic  surgery  must 
arise  from  congenital  defects  or  deficiencies,  from  atrophy  or  wasting  after 
birth,  or  from  actual  losses  of  substance,  whether  by  disease  or  traumatism. 
And  it  is  equally  obvious  that  different  causes  may  bring  about  the  same 
result — deformity — as  in  the  cases  of  excision  of  a  bone  and  its  congenital 
absence;  the  loss  by  mutilation  of  part  of  an  organ,  as  a  muscle,  and  its 
atrophy  from  lesion  of  its  tutelary  nerve ;  and  the  total  loss  of  substance  pro- 
duced as  in  the  cutaneous  structures,  by  traumatism  upon  the  one  hand,  and 
by  disease  upon  the  other.  It  is  unfortunate  that  in  man}'  deformities,  such 
as  arrests  of  development  and  total  deficiencies  of  parts,  the  condition  is  irre- 
mediable;  in  some,  however,  plastic  surgery  alone  may  make  amends; 
whereas  in  others  this  reparative  art  needs  the  aid  of  artificial  appliances  or 
substitutes  which  enlightened  surgery  must  perforce  employ.  And  here, 
before  going  further,  I  would  call  attention  to  the  absolute  necessity  for 
accurate  diagnosis;  for  the  positive  recognition  and  determination  of  the 
nature  of  the  cause  or  lesion,  and  of  the  actual  condition  of  the  part  or  organ. 
Whatever  be,  in  general,  the  need  for  precision  in  matters  surgical,  anticipat- 
ing operative  procedure,  there  is  no  department  of  the  art  in  which  a  correct 
appreciation  of  the  causes  and  consequences  of  deformity,  or  lesion,  leads  to 
better  courses  and  results  in  practice. 

Plastic  surgery  deals,  then,  with  deformities  congenital  or  acquired.  Among 
the  former  are  to  be  ranged  atrophies,  arrests  of  development,  and  infra-uterine 
mutilations,  which  latter  sometimes  involve  a  part  or  the  totality  of  a  mem- 
ber; and,  further,  to  quote  Verneuil,  who  himself  cites  Geoftroy  Saint  Ililaire,2 
as  saying  that  congenital  deformities  are  more  frequently  met  with  at  the 

1  Verneuil,  Art.  Autoplastic.     Diet.  Encyc.  des  Sciences  Medicales.     Paris. 

2  Teratologic      Paris,  1836. 


534  PLASTIC   SURGERY. 

periphery  of  the  body.  "Surgeons  may  make  the  same  remark."  "Arrest 
of  development,  atrophy,  or  mutilation  of  central  parts,  compromise  life  much 
more  certainly  than  the  same  lesions  affecting  the  members,  the  tegumentary 
folds,  the  nose,  lips,  penis,  ear,  etc."  The  further  remarks  of  Verncuil  upon 
deformities,  considered  with  a  view  to  their  relief  by  plastic  surgery,  deserve 
notice  in  this  place,  as  also  his  classification  of  the  lesions  to  which  this 
branch  of  the  art  of  surgery  "has  been  most  happily  applied." 

"  Deformities  by  deficiency,  compatible  with  life,  may  be  arranged  in  three  categories, 
reference  being  had  to  their  radical  cure. 

"(1)  The  absolutely  incurable.  For  example,  the  total  or  partial  absence  of  a 
member,  bone,  or  muscle;  marked  atrophy  in  an  extreme  degree;  loss  of  substance, 
too  deep  or  too  superficial,  but  very  extensive,  are  cases  in  which  autoplasty  can  do 
nothing. 

"  (2)  Cases  in  which  autoplasty  can  only  mask,  palliate,  or  mitigate  the  deformity 
without  being  able  to  restore  both  form  and  function  ;  in  which,  whatever  loss  is  sus- 
tained, absence  of  the  part  cannot  be  compensated  for  by  borrowed  tissue. 

"  (3)  The  last  category  comprises  those  cases  in  which  the  loss  of  substance  is  of 
small  extent,  and  affects  membranous  organs  only.  Nevertheless,  even  in  these  cases, 
the  deformity  may  be  repaired  without  recourse  being  had  to  autoplasty ;  for  example, 
a  vesico-vaginal  fistula  of  the  bas-fond  of  the  bladder,  in  which  the  margins  may  be 
simply  united But  things  are  very  different  if  the  loss  of  sub- 
stance be  great,  if  the  skin  be  naturally  adherent  to  the  subjacent  parts,  if  it  have  lost 
its  flexibility,  its  mobility,  its  extensibility  in  consequence  of  disease.  Here  autoplasty 
becomes  a  necessity." 

And  in  this  place  a  general  view  should  be  presented  of  the  lesions  in  which 
plastic  surgery  has  been  more  or  less  happily  called  upon ;  but  finding  the 
enumeration  of  Verneuil  so  apposite,  we  do  not  hesitate  again  to  draw  mate- 
rial from  his  admirable  article  quoted  above. 

"  (1)  Perforations  and  fistula,  which  establish  a  communication  between  a  cavity,  a 
reservoir,  or  a  mucous  canal,  either  with  a  neighboring  mucous  organ  or  with  the  exterior 
of  the  body. 

"  (2)  Mutilations,  total  or  partial,  of  projecting  appendices,  cutaneous  folds,  or  mem- 
branous curtains,  which  circumscribe  the  natural  apertures. 

"  (3)  Superficial  losses  of  substance,  not  penetrating  into  cavities,  having  destroyed 
a  more  or  less  considerable  extent  of  skin  or  mucous  membrane,  in  a  single  region,  or 
at  the  commissures." 

And  again,  the  state  or  condition  of  the  deformities  under  consideration 
demands  their  division  into  the  following  categories : — 

"  (1)  Those  without  tendency  to  natural  repair. 

"  (2)  Those  met  with  or  created  before  natural  repair  (wounds,  the  extirpation  of 
tumors). 

"  (3)  Such  as  present  themselves  after  nature's  efforts  at  repair." 

It  is  evident  that  in  the  wide  field  of  action  vaguely  defined  in  the  pre- 
ceding  pages,  surgery  lias  offered  to  it  a  great  variety  of  disablements  and 
disfigurements,  produced  under  many  conditions,  but  which  may  be  referred 
f<>  congenital  vices,  arrests  or  absence  of  development,  traumatism  in  atero, 
or  the' result  of  infelicitous  use  of  instruments;  to  injuries  of  all  kinds;  to 
burns;  or  to  the  external  manifestations  of  diseases,  and  their  vicious  ^sponta- 
neous healing  with  loss  of  substance,  or  repair  by  distorting  cicatrices;  to 
gangrene,  and  to  losses  produced  or  provoked  by  wounds,  however  inflicted. 
It  is  equally  apparent  that,  in  dealing  with  these  departures  from  the  nor- 
mal, the  resources  of  plastic  surgery  must  be  taxed,  and  the  aid  of  artificial 
substitutes  or  supports  invoked.  And  not  only  are  these  arts  exercised  upon 
parts  in  which  disease  has  (tone  its  work,  but,  as  in  the  rebellious  ulcers  left 


GENERAL    PRINCIPLES    OF    PLASTIC    OPERATIONS.  535 

by  burns,  heteroplasty,  manipulating  minute  flaps  or  particular  masses  of 
germs,  attacks  by  the  process  of  skin  grafting,  and  forces  repair  in  the  midst 
of  a  tardily  granulating  surface.  Heteroplasty,  formation  by  borrowing  from 
another  organism,  is  also  practised  in  the  transfusion  of  blood,  by  which  por- 
tions of  the  blood  of  man  or  other  animals  are  introduced  into  the  veins  of 
those  who  have  suffered  great  losses  of  the  "mother  of  all  the  tissues,"  and 
who  are  revived  by  the  refreshing  stream.  !NTot  only  so,  but  intravenous 
injections  of  milk  have  been  employed  successfully  by  Prof.  T.  Gaillard 
Thomas  and  others,  in  cases  of  very  considerable  post-partum  hemorrhage. 


General  Principles  of  Plastic  Operations. 

When  all  conditions  agree  in  determining  a  resort  to  plastic  surgery,  no 
principles  which  govern  this  branch  of  the  art  should  be  lost  sight  of.  They 
are  not  numerous,  but  their  application  under  many  circumstances  of  difri- 
culty  requires  the  nicest  exercise  of  judgment,  more  especially  in  certain 
cases  in  which  a  plastic  operation  cannot  be  repeated.  For  example,  in  a 
case  of  double  harelip  which  fell  under  the  writer's  care,  the  lateral  fissures, 
on  either  side  of  the  maxillary  bone,  extended  deeply  towards  the  orbits,  and 
the  clefts  through  the  soft  parts  involved  the  lip,  the  cheeks,  and  the  eyelids, 
and  were  traced  in  each  eye  into  a  coloboma  iridis.  In  this  and  similar 
instances,  an  error  in  judgment,  compromising  much  marginal  substance, 
might  defeat  the  present,  as  it  would  most  probably  the  final,  success  of  an 
operation  otherwise  well  devised.  The  risks,  however,  of  failure  in  difficult 
cases,  those  in  which  arrest  of  development  has  left  considerable  and  intri- 
cate spaces,  or  in  which  disease  or  traumatism  lias  produced  deformities 
demanding  for  their  relief  an  appeal  to  all  the  resources  of  art,  are  diminished 
by  dividing  the  proposed  operation  into  a  number  of  lesser  operations,  or 
seances,  so  that,  like  an  Alpine  mountaineer,  the  surgeon  shall  undertake  no 
step  forward  until  abundant  security  has  been  obtained  for  the  advance. 
Thus  an  original  operation,  limited  in  its  scope,  may  be  made  the  foundation 
of  a  series  of  secondary  procedures,  the  success  of  each  of  which  will  render 
that  of  its  follower  less  doubtful,  and  wrill  multiply  the  chances  of  a  favorable 
issue  for  the  case. 

A  comparison  of  deformities  and  lesions  will  serve  to  arrange  them  all  into 
two  groups,  as  far  as  plastic  surgery  is  concerned;  the  first  requiring  for  its 
extinguishment  or  repair  simple  approximation  of  parts — widely  sundered,  it 
is  true,  but  separated  by  the  unopposed  and  not  vigorous" traction  exerted  by 
the  physical  properties  of  some  of  its  elements,  and  the  vital  property  of  others ; 
the  second  necessitating  a  borrowing  from  the  immediate  or  remote  neigh- 
borhood, and  the  localization  and  interpolation  of  new  flaps  or  pieces.  It 
may  be  claimed  as  self-evident,  as  it  is  also  shown  in  practice,  that  the 
frequency  of  fortunate  results  in  the  former  group  is  in  accordance  with  the 
lack  or  low  degree  of  tension,  and  with  the  analogy,  or  rather  identity  in 
nature,  of  the  tissues  restored  to  their  original  relation,  or  even,  urged  a  little 
farther,  made  to  bridge  over  a  gap  left  by  a  minor  loss  of  substance.  In  the 
latter  group,  the  same  absence  of  stretching  or  tension  must  mark  the  adjust- 
ment of  flaps,  and  the  same  analogy  of  tissues  must  be  preserved  in  the  selec- 
tion of  pieces  to  be  permanently  transposed.  Besides  all  this,  it  is  requisite 
and  necessary  that  the  flaps  should  be  well  provided  with  nutrient  vessels, 
whether  they  be  destined  to  retain  their  continuity  with  the  mother  tissues. 
or  to  lose  their  original  basal  attachment  by  severance  as  soon  as  they  shall 
have  acquired  sufficient  adhesion  in  their  new  position.  It  must  also  suggest, 
itself  to  the  surgeon  that  hairy  parts  should  not,  if  possible,  be  repaired  with 


536 


PLASTIC   SURGERY. 


bare  flaps,  and  that  hairy  flaps  should  not,  upon  pain  of  ridiculous  disfigure- 
ment of  the  patient,  be  translated  to  regions  normally  devoid  of  hair.  The 
end  of  a  re-made  nose  would  be  an  undesirable  termination  of  that  organ,  if 
it  were  made  to  bear  a  tuft  derived  from  a  well-covered  scalp. 

Another  circumstance  tending  towards  the  successful  ending  of  a  plastic 
operation,  is  recognition  of  a  due  proportion  between  the  size  of  the  gap  to 
be  filled  or  bridged  over,  and  that  of  the  flap.  And  it  must  be  well  borne  in 
mind  that,  as  by  cicatrization  a  "  natural  autoplasty"  (Verneuil)  is  accom- 
plished by  the  simple  traction  of  the  cicatricial  tissue,  it  may  be  necessary, 
under  different  circumstances,  to  employ  a  flap  smaller,  the  size  of,  or  much 
larger  than  the  space  to  be  covered.  A  flap  borrowed  from  situations  in 
which  the  tissues  are  lax,  ought  to  be  many  times  larger  than  the  opening  or 
chasm  ;  for,  by  the  natural  elasticity  of  its  elements,  the  flap  is  greatly  reduced 
in  size,  and,  inasmuch  as  it  will  not  bear  tension,  scantiness  of  material  may 
lay  the  foundation  of  failure  in  the  operation  by  rendering  firm  union  between 
the  freshened  surface  and  the  borrowed  piece  impossible,  and  by  inviting  and 
producing  inflammation  and  gangrene.  Of  course,  such  a  condition  of  things 
would  be  a  misfortune,  since  positive  and  extensive  loss  of  substance  in  the 
flap,  or  destruction  of  its  totality,  is  usually  repaired  with  difficulty,  if  even  the 
damage  thus  occasioned  should  not  preclude  the  possibility  of  a  repetition  of 
the  operation.  Wherefore  the  surgeon  must  assure  himself  of  the  just  pro- 
portions, as  well  as  of  the  form,  of  the  proposed  flap,  making  due  allowance 
for  shrinkage  as  well  as  for  ulterior  atrophy,  which  sometimes  follows  a  per- 
fect union.  But  even  here,  it  may  be  added  that  flaps  of  sufficient  thickness, 
as  well  as  size,  and  abundantly  provided  with  bloodvessels,  are  much  less 
liable  to  ulterior  atrophic  contraction. 


Classification  of  Plastic  Operations. 


From  what  has  been  said,  it  will  readily  be  admitted  that  all  plastic 
operations  may  be  arranged  in  five  categories.  The  first  comprises  all  those 
in  which  the  borrowed  piece  is  obtained  from,  a  distance  and  transferred 
directly  to  the  seat  of  its  future  residence,  retaining,  however,  for  a  time  not 
determinable  with  precision,  its  connection  by  means  of  a  pedicle  with  the 
tissues  of  its  original  site  ;  to  the  second  belong  those  cases  in  which  the  auto- 
plasty is  accomplished,  after  the  method  of  Roux,  by  "  successive  migrations''' 
of  the  flap,  from  a  point  more  or  less  remote  ;  the  third  includes  all  operations 
in  which  the  flap  or  flaps  are  derived  from  the  neighborhood,  and  are  moved 
into  place  by  gliding,  or  made  to  assume  proper  relations  by  stretching  or  by 
lapping  over,  as  when  a  periosteal  flap  is  made  to  cover  the  end  of  a  severed 
bone  after  amputation ;  the  fourth  embraces  all  those  operations  of  simple 
approximation,  as  after  the  V-shaped  piece  is  removed  for  the  relief  of 
ectropion,  or  for  the  attempted  cure  of  epithelioma  of  the  lip,  or,  more 
primitively,  when  the  freshened  "  vivified"  edges  of  a  vesico-vaginal  fistula 
are  brought  into  contact,  and  maintained  in  apposition  with  more  or  less 
tension.  Under  the  same  caption  may  be  inscribed  several  of  the  methods 
for  bringing  about  adhesion  in  ununited  fractures  of  the  bones,  the  broken 
ends  being,  under  some  circumstances,  vivified,  and  made  adherent  to  one 
another  by  means  of  silver  wire,  or  of  a  screw  or  screws  of  the  same  metal. 
Lastly,  the  fifth  category  comprehends  all  readjustments  of  totally  severed 
parts,  as  a  nose  or  a  tooth,  autnentic  instances  of  which  species  of  repair  are 
not  sufficiently  infrequent  to  be  wonderful.  In  this  category  are  also  to  be 
enumerated  the  famous  skin  grafting  by  greffes  ipidermiques,  or  dernio- 
epidermiques  of  llevcrdin ;  the  grafting  by  larger  bits,  or  anaplasty,  of  See, 


GENEKAL  RULES  FOR  PLASTIC  OPERATIONS.  537 

Oilier,  and  Poncet ;  the  transplantation  of  particular  or  greater  morsels 
derived  from  a  stranger  organism,  heteroplastt/,  whether  that  be  human  or 
animal ;  and,  finally,  transfusion  of  blood. 


General  Rules  for  Plastic  Operations. 

In  the  majority  of  the  operations  and  methods  enumerated, 'immediate 
union,  or  union  by  the  first  intention,  of  the  newly  juxtaposited  parts,  is  the 
aim  and  hope  of  the  surgeon,  although  sloughing  or  gangrene  to  a  small 
extent  may  not  wholly  defeat  the  intention  of  the  operator.  But  a  scrupulous 
attention  to  the  general  condition  and  surroundings  of  the  patient,  the  adop- 
tion of  a  carefully  studied  plan  of  operation  and  observance  of  its  minutest 
details,  and  a  sagacious  and  watchful  after-management  of  the  case,  are  cir- 
cumstances which  lead  to  if  they  do  not  insure  success,  and  which  must  be 
had  in  view  and  closely  followed  out  if  success  is  to  be  the  issue.  Among 
the  evil  consequences  of  an  unwise  disregard  of  detail,  may  be  mentioned 
gangrene,  as  depending  upon  a  poverty  of  the  nutrient  supply  of  the  flaps, 
whether  by  reason  of  its  attenuate  pedicle,  its  thinness,  the  scantiness  of 
bloodvessels  in  the  pedicle,  or  their  choking  by  excessive  tension  or  twisting, 
or  upon  want  of  protection.  The  manner  of  making  the  sutures,  the  choice 
of  proper  material  for  them,  and  the  distance  from  each  other  at  which  they 
are  placed,  will  and  must  influence  the  mode  and  time  of  union  of  the  wedded 
parts,  and  bring  about,  or  not  allow  or  favor,  union  by  first  intention.  And 
thus  portions  along  the  line  may  fail  to  heal,  and  suppuration  may  perma- 
nently interfere  with  a  union  which,  in  other  situations,  is  firm  enough. 
And  a  disregard  for  the  quality  of  the  air  in  which  the  subject  of  the  opera- 
tion lives,  as  loaded  with  the  miasmata  of  fever  or  erysipelas,  or  the  preva- 
lence of  the  latter  disease  as  an  epidemic,  may  not  only  set  the  operative  skill 
of  the  surgeon  at  naught,  but  may  open  a  door  in  the  patient's  body  for  the 
entrance  of  a  fatal  complication. 

In  this  connection,  a  very  important  circumstance  ought  to  be  made  con- 
spicuous, and  this  is  that  the  hiatus  left  by  the  forced  loan  imposed  upon  an 
innocent  feature,  must  itself  be  the  subject  of  the  same  interest  which  attaches 
to  the  locality  benefited.  It  may  sometimes  be  left  to  cicatrization  and  ulti- 
mate shrinking  of  the  scar,  but  not  unfrequently  adhesive  straps  invite  or 
force  approximation  of  separated  margins,  with  or  without  preliminary  loosen- 
ing of  the  integument  and  connective  tissue  done  with  a  view  of  facilitating 
approach,  or  linear  or  crescentic  incisions  may  be  employed  to  transfer  de- 
formity to  unimportant  situations,  by  promoting  instant  adhesion  of  tissue 
margins  separated  by  loss  of  substance.  It  was  with  this  intention  that  the 
writer,  after  removing,  by  a  long  elliptical  incision,  a  considerable  melanotic 
tumor  from  the  front  of  the  thigh  of  an  itinerant  Methodist  preacher,  who 
made  his  circuits  on  horseback,  practised  on  either  side  of  the  longitudinal 
gap  a  deep  incision  parallel  with  the  neighboring  margin,  dissected  up  the 
bands  lying  between  the  incisions  and  elliptical  space,  and  brought  the 
margins  together  in  a  line  on  the  convexity  of  the  thigh.  Immediate  union 
occurred  along  the  whole  extent  of  the  line,  while  the  lateral  cicatrices  were 
so  placed  as  to  escape  friction  from  clothing  or  other  matters  which  the  front 
of  the  thigh  was  called  upon  to  bear. 

But  loss  of  substance,  if  it  be  of  limited  extent,  may  not  always  require 
the  translation  of  a  flap,  or  may  not  call  for  any  further  abstraction  of  tissue. 
Thus  for  freshening  the  margins  of  some  buccal  fistula?,  experience  has 
shown  the  advantage  to  be  derived  from  the  employment  of  the  actual 
cautery,  or  the  thermo-cautery  of  Paquelin,  applied  at  a  dull-red  heat  and  at 


538  PLASTIC    SURGERY. 

several  sittings,  the  operator  relying  upon  the  cicatricial  contraction  produced 
by  the  healing  of  the  successive  burns,  for  the  extinguishment  of  the  distress- 
ing and  unsightly  aperture. 

Among  the  interesting  documents  which  bear  upon  this  subject,  I  would 
refer  the  reader  to  one  by  J.  R.  Marinus,1  entitled  "Considerations  upon 
Heteroplasty  or  Autoplasty  by  Heterogeneous  Transplantation,"  a  compendium 
of  remarkable  cases  of  parts  restored  and  replaced.  This  author  quotes 
Reissiger,2  as  being  the  first  who  proposed  to  replace  an  opaque  human 
cornea  with  a  healthy  one  derived  from  an  animal  [an  operation  which  has 
been,  of  late  years,  successfully  resorted  to  in  several  instances] ;  and  after- 
wards Msesner,  and  subsequently  Dietfenbach,  who  both  attempted  "kerat- 
oplasty "  upon  animals,  but  whose  experiments  led  them  to  the  conclusion 
that,  since  the  cornea  when  nearly  separated  did  not  reunite,  transplantation 
to  another  eye  offered  still  fewer  chances  of  success.  And,  on  the  other  hand, 
Marinus  assures  us  that  Rudiman  reports  that  in  India  belief  is  so  strong  as 
to  the  possibility  of  reunion  of  a  cut-off  nose,  that  the  executioner  is  com- 
manded to  throw  the  piece  into  a  brazier,  to  prevent  readjustment. 

In  this  country,  as  is  well  known,  plastic  surgery  has  been  much  cultivated, 
and  practised  with  remarkable  suceess.  The  operations  and  most  valuable 
contributions  of  Prof.  Joseph  Pancoast  are  guides  and  texts  for  surgeons,  and 
the  work  and  practice  of  Mutter  are  monuments  in  this  department  of  the 
art  of  surgery,  but  we  would  regard  this  notice  as  incomplete  without  refer- 
ence being  made  to  Prof.  Gilbert,3  among  whose  successful  cases  may  be  men- 
tioned the  construction  of  two  noses  by  the  Indian  method ;  to  Dr.  Gurdon 
Buck,4  whose  triumphs  are  familiar  in  the  department  of  restorations ;  and 
to  Dr.  Detmold,5  to  whom  both  the  profession  and  the  public  owe  so  much. 


Skin  Grafting. 

Under  theffth  caption  we  have  grouped,  and  therefore  associated  together, 
a  number  of  facts  which  acquire  relationship  by  reason  of  the  complete  sepa- 
ration of  the  parts  re-applied  and  fixed  by  restitutive  autoplasty,  as  of  the 
nose,  of  which  Hoftlieher,  officially  present  at  duels  with  rapiers  fought  at 
Heidelberg,  reports  several  successful  cases,  and  notably  one  in  which  the 
organ  lopped  oft'  was  seized  by  a  dog,  but  being  rescued,  although  cold  and 
moist,  was,  after  careful  cleaning,  re-attached.  Bits  of  fingers,  lopped  off, 
have  been  known  to  adhere  vitally  after  replacement,  and  teeth  also  have 
taken  hold  when  transplanted;  indeed  transplantation  of  these  ornaments  of  the 
mouth  was,  within  a  century,  a  fashion  in  some  countries,  in  which,  it  is  said, 
sound  front  teeth  of  fresh  country  girls  were  purchased  by  fading  belles  to 
replace  their  own  carious  incisors  or  canines.  It  is  remarkable  that  with  such 
experiences,  which,  perhaps,  were  not  confined  to  the  later  centuries,  surgeons 
so  slowly  recognized  the  facts,  first,  that  portions  of  the  living  body  might  be 
sundered  from  it  without  immediately  losing  life;  and,  secondly,  that  these 
portions,  so  removed,  could  contract  vital  adhesion  with  another  part  of  the 
same  individual,  or  will)  some  part  of  another  person  or  creature.  But,  like 
the  discovery  of  the, circulation  of  the  blood,  the  separate  anatomical  and 
physiological  truths  of  which  were  known  even  from  the  time  of  Galen,  the 

1  Annates  de  La  Sooi6t6  de  M6decine  d'Anvers,  1842. 

2  Baier'aohe  Annalen,  L824,  Bd.  i.,  Stuck  1,  S.  209-215. 

3  Med.  Examiner,  new  series,  vol.  vii.     Philadelphia,  1851. 

4  Bulletin  <>f  the  New  York  Academy  <>f  Medicine,  vol.  iii.,  and  elsewhere. 

5  Bulletin  of  the  New  Yurk  Academy  of  Medicine,  vol.  iii.     Paper  upon  Plastic  Surgery. 


SKIN   GRAFTING.  539 

discovery  of  the  phenomena  of  germination  of  anatomical  particles  when 
transplanted,  was  reserved  for  very  modern  times,  although  glimpses  of  the 
real  significance  of  the  process  of  healing  of  wounds  and  ulcers  had  been 
enjoyed  in  early  ages. 

Perhaps  Prof.  Frank  II.  Hamilton,  of  New  York,  may  be  regarded  as  the 
first  who  attempted  to  generalize  upon  the  experience  of  the  past,  when,  in 
his  clinique  at  the  Dispensary  of  the  Geneva  Medical  College,  in  January, 
1847,  he  proposed  to  a  boy  of  fifteen  years  a  plastic  operation,  with  the  view 
of  planting  upon  the  centre  of  an  ulcer  a  piece  of  new  and  perfectly  healthy 
skin,  taken  from  the  calf  of  the  other  leg,  and  not  intending  to  cover  over  the 
whole  sore,  but,  perhaps,  two  or  three  square  inches,  which  he  believed  would 
be  enough  to  secure  the  closure  of  the  wound  in  a  short  time.1  And  the 
reporter  affirms  that  this  proposition  had  been  made  to  the  lad  two  years 
before.  Dr.  Hamilton's  earliest  operation  of  the  kind  was  not  done,  however, 
until  January  21,  1854,  upon  Horace  Driscoll,  in  the  Buffalo  Hospital  of  the 
Sisters  of  Charity.  An  account  of  this  operation,  contained  in  a  paper  enti- 
tled "Old  Ulcers  treated  by  Anaplasty,"  read  before  the  Buftalo  Medical 
Association,  June  27, 1854,  was  published  in  the  New  York  Journal  of  Medicine 
in  September  of  that  year.  In  the  summary,  the  following  remarkable  sen- 
tence forms  the  fourth  of  six  propositions:  "If  [the graft  be]  smaller  than  the 
chasm  which  it  is  intended  to  fill,  the  graft  will  grow,  or  project  from  itself 
new  skin  to  supply  the  deficiency."  The  fifth  proposition  refers  to  a  probable 
expansion  of  the  graft,  and  the  sixth  asserts*  that  "in  consequence  of  one  or 
both  of  these  two  latter  circumstances,  it  will  not  be  necessary  to  make  the  graft 
so  large  as  the  deficiency  it  is  intended  to  supply."  In  this  we  observe  the 
declaration  of  a  principle,  not  new  in  fact,  but  original  in  its  direct  suggest- 
iveness,  implying  a  knowledge  of  the  strength  of  border  growth  of  new  skin 
in  an  ulcer,  of  the  weakness  of  the  middle  part,  and  also  of  the  means  likely 
to  repair,  or  capable  of  remedying,  the  deficiency.  The  fact  was  known  long 
before,  and  is  still  familiar  in  the  text-books  of  surgery,  as  we  find  Erichsen 
saying,  "Indeed,  if  the  ulcer  be  large,  there  may  not  be  enough  [new  skin] 
for  the  cicatrization  of  the  centre."  What  Hamilton  accomplished,  and  no 
doubt  intended,  if  his  words  mean  anything,  was  the  establishment  of  a  new 
basis  of  skin-formation  where  it  was  most  needed,  and  his  credit  does  not  rest 
upon  the  performance  of  a  simple  anaplasty. 

The  generalization  of  the  idea  which  guided  Hamilton  was  made  by  Dr.  J. 
L.  Reverdin,  interne  laureat  of  the  Hospitals  of  Paris,  in  1869,  for  on  the  8th 
of  December  of  that  year  he  presented2  before  the  Society  of  Surgery  a  patient 
who  belonged  to  the  service  of  his  "excellent  master,"  Dr.  Guyon,  and  on 
whom  he  had  practised  a  new  experiment,  for  which  he  proposed  the  name 
of  epidermic  grafting.  It  consisted,  to  use  his  own  words,  "  in  transporting  to 
a  granulating  wound  little  bits  formed  out  of  the  superficial  parts  of  the  in- 
tegument." 

"  This  experiment  had  been  suggested  to  me,"  he  says,  in  an  admirable  article  pub- 
lished a  few  years  later,3  "  by  having  observed  little  epidermic  islands  which  formed 
spontaneously  in  certain  wounds  ;  I  asked  myself  if,  by  a  graft,  we  might  not  obtain 
the  formation  of  similar  little  islands  of  cicatrization,  and  thus  hasten  the  cure;  therein 
was  a  double  interest,  physiological  and  practical.  The  result  was  such  as  I  dared 
hardly  hope  ;  not  only  did  the  little  morsels  continue  adherent  to  the  granulations,  hut 
presently  they  began  to  extend*  and  form  an  island  of  cicatrization."  And  then  the 
author,  surveying  the  field  likely  to  be  covered  by  skin  grafting,  reproduces  a  part 

'  Buffalo  Med.  and  Surg.  Journal,  Feb.  1847,  p.  508. 

2  Bulletin  de  la  Societe"  de  Chirurgie,  1869  ;  Gazette  des  Hopitaux,  Janvier,  1870  ;  British  Med. 
Journal,  Dec.  10,  1870. 

3  Archives  Generates  de  Mfidecine,  1872,  t.  i.  pp.  276,  555,  703. 


540  PLASTIC    SURGERY. 

of  his  communication  to  the  Societe  de  Chirurgie,  and  concludes  with  these  words : 
"  Finally,  I  shall  have  to  study,  as  much  as  possible,  the  histological  process.  Is  there 
here  the  simple  effect  of  contact,  or  vicinity  ?  Is  there  proliferation  of  the  transplanted 
elements?"  During  the  progress  of  experimentation,  many  questions,  of  course,  arose, 
which  have  not  yet  all  been  answered  ;  but  after  the  adherence  of  the  grafts  was  accom- 
plished, and  epidermis  was  observed  toform  around  them,  Reverdin  came  to  the  conclusion 
that  "  the  epidermis  by  itself,  but  still  the  living  epidermis,  that  of  the  deep  layer, 
would  alone  be  necessary  for  the  success  of  the  grafting."1  And  again,  "the  adherence 
of  the  graft  is,  therefore,  effected  by  the  epidermis;  the  welding  of  the  dermis  is  but 
secondary  and  accessory  ;  the  part  played  by  the  dermis  in  the  properties  of  the  formed 
islets  is,  therefore,  completely  null."  But  the  grafts  remain,  and  are  not  absorbed  ;  yet, 
as  Poncet2  expresses  the  idea,  "  The  cutaneous  graft  not  only  is  not  re-absorbed,  but  it 
possesses  all  the  properties  of  the  skin." 

The  views  entertained  by  Reverdin  with  regard  to  the  epidermis  seemed 
to  him  to  find  confirmation  in  "  a  little  fact"  which  was  that,  in  some  cases, 
he  found  upon  the  strips  of  plaster  grafts  which,  put  in  place  the  evening 
previous,  had  failed  to  unite,  but  which,  upon  being  replaced,  "  took "  per- 
fectly.3 We  shall  see,  further  on,  that  Georges  Martin,4  in  his  thesis  "  upon 
the  duration  of  the  vitality  of  the  tissues  and  of  the  conditions  of  adherence  of 
cutaneous  restitutions  and  transplantations,"  ascertained,  through  observations 
of  his  own,  that  some  separated  bits  of  human  skin  maintained  their  vitality, 
when  exposed  in  free  air,  for  ninety -six  hours,  and  others  in  a  confined  space 
for  one  hundred  and  eight  hours,  at  a  temperature  of  nearly  zero,  C.  [32°  F.]. 

Hamilton  failed  to  perceive  that,  without  peduncular  attachment,  his  little 
flap  might  adhere  and  grow  ;  but  Reverdin  saw  this,  and  so  earned  his 
honors.  He  communicated  his  discovery  to  the  Societe  de  Chirurgie  on  the 
8th  of  December,  1869  ;  the  commission  to  which  it  was  referred,  consisting 
of  MM.  Guyon,  Chassaignac,  and  Despres,  made  a  report ;  and  Guyon,  in 
whose  service  the  experiments  were  made,  presented  the  subject  verbally, 
and  provoked  a  discussion  hardly  favorable  to  skin  grafting.  But  Verneuil 
declared  himself  in  favor  of  the  method,  which  he  believed  was  calculated  to 
render  service  in  many  departments  of  surgery.  Gosselin,  Guyon,  Alphonse 
Guerin,  and  Duplay  offered  encouragement,  and  extended  facilities  ;5  and 
Marc  See  dispelled  the  bad  impressions  remaining  by  presenting,  six  months 
afterwards,  a  patient  who  bore  evidence  of  the  success  of  the  operation,6  in 
w  1 1  ich  See  had  been  aided  by  Reverdin  himself. 

Grafting  now  became  the  fashion ;  M.  Vulpian7  presented  before  the 
Societe  de  Biologie,  in  the  name  of  M.  J.  M.  Phillipeaux,  a  case  of  transplan- 
tation of  the  spur  of  a  young  cock  of  forty  days  upon  the  comb  of  the  same 
animal,  in  which  the  spur  became  incorporated  with  the  skin,  formed  no 
adhesioD  with  the  cranial  bones,  but  surpassed  in  length  its  non-transplanted 
fellow.  Some  grafted  the  skin  of  the  white  man  upon  the  negro;8  or  took 
grafts  from  moles  or  parts  stained  with  India  ink;9  or  borrowed  skin  from 
amputated  members  ;10  or  even  supplemented,  in  the  case  of  a  large  ulcer  after 
a  bum  in  a  little  girl,  some  three  hundred  grafts  from  the  patient  herself, 

■  Loc.  cit.,  p.  707.  2  Lyon  Medical,  t.  xiv.  pp.  293,  294,  1873. 

3  Loc.  cit.,  p.  709.  *  Georges  Martin,  These,  Paris,  1873. 

«  Archives  Gen.  de  Med.  1872,  t.  i.  p.  277.    » 

G  M.  Sir,  Gazette  Bebdom.  <le  Paris,  Juillet  20,  1870;  J.  Ustariz,  Sobro  los  Ingertos  en  gene- 
ral, etc.  Anfiteatro  Anat.  Eapafiol.  Madrid,  1877;  and  E.  T.  Easley,  Am.  Med.  Weekly,  Louis- 
ville, Ky.,  187(5,  vol.  iv.  p.  353. 

?  Comptcs  rendus  des  Seances  et  Mem.  de  la  Soc.  de  Biologie,  t.  ii.  5e  Serie,  Annee  18*70. 

*  G.  T.  Maxwell,  Philad.  Med.  Times,  1873,  p.  37. 

9  J.  T.  Bodgen,  Cell  or  Skin  Grafting.    St.  Louis  Med.  and  Surg.  Journ.,  1871. 

10  B.  Anger,  Bur  l'Beteroplastie.  Comptes  rendus  liebdom.des  Seances  de  l'Acad.  des  Sciences, 
t.  lxxix.  p.  1210.     Paris,  1874. 


SKIN   GRAFTING.  541 

with  a  score  of  others  derived  from  a  young  pig.1  Animals,  also,  were  made 
the  subjects  of  experimentation  ;  indeed,  some  years  before  1869,  with  regard 
to  animal  grafting  it  was  proposed  to  "unite,"  or  "glue  together,"  two  ani- 
mals by  their  cutaneous  envelopes,  and  even  animals  of  different  species.3 
Some,  like  Reverdin,  preferred  small  grafts ;  others,  as  M.  Oilier,3  thought 
better  of  larger  ones,  even  reaching  the  dimensions  of  eight  square  centimel  res, 
or,  as  Donnelly,*  employed  those  of  a  diameter  of  a  quarter  of  an  inch.  Savrey, 
quoted  by  Georges  Martin,5  asserts  that  "  two  Swedes,  to  give  each  other  a 
durable  remembrancer,  exchanged  a  bit  of  skin  of  the  inside  of  the  forearm ;" 
but  the  most  remarkable  graft  ever  applied  was  one  of  which  we  find  the 
account  in  the  discourse  of  Ustariz  already  referred  to.     It  is  as  follows: — 

"  Armaignac  says  that,  in  the  seventeenth  century,  there  is  seen  a  light  glimmering  in 
this  direction,  quoting  a  case,  related  by  an  ecclesiastic  named  Kraemoinkel,  of  a 
soldier  who  had  lost  a  large  part  of  the  hairy  scalp  and  of  the  bone  beneath  it,  the 
surgeon  closing  this  opening  with  a  portion  of  bone  and  skin,  of  the  same  form  and 
dimensions,  taken  from  a  dog  which  he  killed  for  the  purpose.  As  it  appears,  the  Church 
being  apprised  of  the  matter,  there  were  launched  against  the  poor  surgeon  all  the 
anathemas  and  furies  of  which  that  institution  is  capable  ;  and  it  became  necessary  for 
his  return  into  the  communion  of  the  faithful  that  he  should  practise  a  new  operation 
upon  the  unfortunate  soldier,  ridding  him  of  that  unclean  spoil  of  dog  which  had 
become  strongly  consolidated  with  the  adjacent  parts,  and,  as  Armaignac  facetiously 
remarks,  subjecting  him  to  a  treatment  more  conformable  to  the  Christian  character." 

The  whole  matter  of  skin,  or,  as  Reverdin  calls  it,  epidermic  grafting,  was 
liberally  treated  by  that  author  in  the  Archives  Ginerales  de  Medicine  for  the 
year  1872.  His  method,  exceedingly  simple,  may  be  expressed  in  a  few 
words.  Taking  usually  his  little  bits  from  the  inner  surface  of  the  leg,  he 
rendered  the  skin  tense  over  the  flat  surface  of  the  tibia,  and  introduced  the 
point  of  a  rather  large  venesection  lancet  parallel  to  the  bone,  and  to  the  depth 
of  a  half  millimetre;  then  pushing  it  forward  so  that  the  point  should  emerge 
three  or  four  millimetres  further  on,  the  little  piece  was  cut  loose  by  the 
edges  of  the  instrument.  "  The  little  wound,"  he  adds,  "is  the  seat  of  a  fine 
sanguineous  dew."  "I  apply," continues  the  author,  "my  lancet, bearing  the 
graft,  upon  the  granulations  which  I  have  selected,  and  slide  it  upon  them 
with  the  point  of  a  pin.  It  is  thus  in  relation  with  the  granulations  by  its 
deeper  face,  and  I  ascertain,  by  a  motion  from  side  to  side,  that  no  part  of  its 
edge  is  rolled  up,  for  it  is  necessary  that  it  should  be  completely  spread  out. 
This  result  once  obtained,  and  all  my  grafts  in  place,  I  cover  them  with  strips 
of  diachylon  plaster,  which  are  not  removed  for  twenty-four  hours."  Some- 
times the  grafts  were  furnished  by  the  subject  himself;  at  other  times  they 
were  successfully  borrowed  from  a  different  person;  now  they  were  obtained, 
as  at  Guy's  Hospital  and  at  St.  Bartholomew's,  from  limbs  recently  ampu- 
tated; or,  again,  they  were  derived  from  the  cadaver,  soon  after  death,  as  by 
M.  Prudhomme.8  One  fact,  sa}'s  Reverdin,  would  be  of  great  importance  "  if 
it  were  perfectly  demonstrated."  Dobson  and  Laroyenne7  found  it  necessary 
and  advantageous  to  borrow  grafts  from  young  subjects  to  implant  upon  aged 
patients.  But,  from  his  own  experience,  the  inventor  of  the  process  does  not 
"venture  to  draw  a  definitive  conclusion"  upon  this  point.     AVe  learn  also 

1  Thomas  F.  Raven,  British  Medical  Journal,  London,  1877,  vol.  ii.  p.  623. 

2  P.  Bert,  Exp.  et  Consid.  sur  la  Greffe  Animale.  Journal  de  l'Anat.  et  de  la  Physiol,  nor- 
male  et  path.,  t.  i.  pp.  64,  87.     Paris,  1864. 

3  Oilier,  Sur  les  Greffes  Cutanees  ou  Autoplastiques.  Bull,  de  l'Acad.  de  Medecine,  Paris, 
1S72,  pp.  242,  246. 

«  Donnelly,  New  York  Med.  Record,  1872,  p.  572. 

5  Georges  Martin,  op.  cit.  p.  14. 

6  Lancet,  May  20,  1871  ;  These  de  Colrat  ;  Reverdin,  loc.  cit. 

1  Med.  Times  and  Gazette,  Oct.  29,  1870 ;  Colrat,  op.  cit.  ;  Reverdin,  loc.  cit. 


542  PLASTIC    SURGERY. 

from  Reverdin's  memoir  that  grafts  were  taken  by  himself  and  others  from 
negroes;  that  little  bits  derived  from  different  animals  could  be  successfully 
grafted;  and  also  that  Czerny  and  others  had  transplanted  pieces  from  the 
mucous  membranes. 

We  have,  so  far,  traced  in  brief  detail  the  method  of  the  pioneer  himself, 
and  reproduced  his  views  at  some  length,  for  the  reason  that  his  observations 
were  so  exact,  and  his  practice  so  sure,  that  those  who  followed  him  made 
but  little  change  in  the  plans  proposed,  found  few  opportunities  for  new 
applications  of  the  practice,  and  emitted  not  many  original  views  as  to  the 
plans  of  operating,  the  mode  of  attachment  of  the  bits  of  tissue,  or  the 
general  laws  of  physiology  applicable  in  the  mass  of  cases,  or  in  particular 
instances.  But  real  progress  was,  perhaps,  determined  by  the  recognition  of 
the  elements  upon  which  proliferation  depended,  and  of  the  fact  that  the 
marginal  cicatrix  was  formed  from  all  the  borders  of  the  grafts;  although 
IsT.  C.  Dobson1  had  declared,  as  early  as  1870,  that  the  growth  of  cicatrix  was 
not  unlimited,  and  that  no  one  island  exceeded  the  dimensions  of  a  sixpence. 
And  the  same  may  be  said  with  regard  to  the  conditions  necessary  to  success, 
for,  as  all  ulcers  tend  towards  or  must  be  brought  to  the  form  of  the  common 
or  typical  ulcer  in  the  process  of  healing,2  so  must  all  ulcers,  for  a  favorable 
reception  of  the  grafts,  be  already  covered  with  willing  granulations,  or  be 
made  to  be  covered  with  them.  To  express  the  same  idea  in  the  words  of 
Reverdin,  "the  end  to  be  attained  when  we  wish  to  prepare  a  wound  for 
grafts,  is  to  obtain  [a  surface  of]  granulations  as  well  denned  as  possible." 
And  it  is  here  of  interest  to  record  the  fact  that,  in  speaking  of  the  growth 
of  the  little  islands,  as  determining  the  rapidity  of  cicatrization,  Reverdin 
informs3  us  that  the  observation  of  a  case  of  ulcer  in  which  the  formation  of 
pellicle  advanced  from  spontaneous  " Hots"  gave  him  the  first  idea  of  " la 
greff'e  epidermiqae." 

But  rapidity,  although  promoting  a  prompt  cure,  was  found  to  be  asso- 
ciated with  solidity,  and  this  latter  quality  with  permanency.  For  a  time, 
says  Reverdin,  the  cicatrix  due  to  the  grafts  is  a  little  prominent,  but  event- 
ually becomes  depressed  "as  an  umbilicus;"  then  around  the  grafts  is  formed 
a  whiter,  thicker,  and  more  solid  cicatrix,  and  one  which  resists  relapses.4 
And  although  his  facts  were  few,  still  results  seemed  to  point  to  the  conclu- 
sion that  "cicatricial  retraction  and  vicious  cicatrization"  were  opposed,  rather 
than  favored,  by  the  new  process.5  "I  can  now  conclude,"  says  Reverdin, 
"(1)  That  by  grafting  we  may  prevent  the  adhesion  {soudure)  of  two  neigh- 
boring granulating  surfaces.  (2)  That  as  for  retraction,  reasoning  and  certain 
facts  demonstrate  that  it  can  be  prevented,  at  least  in  part,  by  means  of 
grafts.  (3)  That  the  applications  [of  grafts]  made  for  the  cure  of  certain 
deformed  cicatrices  have  given  good  lesults;  these  results  should  be  verified 
by  time." 

There  remiiins  to  be  briefly  noticed  Reverdin's  view  with  regard  to  the  part  taken  by 
certain  elements  in  the  formation  of  a  cicatrix,  and  to  do  this  1  will  reproduce  his 
language,  premising  the  quotation  with  his  statement  that,  "  on  account  of  pain  and 
possible  accidents,  small  grafts  are  preferable."6  Thus:  "The  epidermis  by  itself,  but 
the  living  epidermis,  thai  of  the  deep  layer,  is  alone  necessary  for  the  success  of  the 
graft."7  "The  adherence  of  the  graft  is  accomplished,  then,  by  the  epidermis;  the 
union  of  the  dermis  is  only  secondary  and  accessory."8  And  finally,  the  opinion  is 
expressed  that  we  can  greatly  facilitate  the  cure  of  rebellious  wounds  of  which  the 
duration  bears  no  relation  to  their  extent. 

i  Med.  Tim.-s  and  Gazette,  Oct.  20,  1870,  p.  f>00 ;  Reverdin,  loc.  cit. 

2  Paget,  in  Bolmea'B  System  of  Surgery. 

3  Loc.  <-it.,  |>.  555.  4   Loc.  cit.,  p.  .r>(54.  s  Loc  cit,,  p.  571. 
6  Loc.  cit.,  p.  711.                            7  Loc.  cit.,  p.  707.                          8  Loc.  cit.,  p.  708. 


SKIN    GRAFTING.  543 

A.  Poncet,  in  the  previous  year,  1871,  had  reviewed  the  whole  matter,  method  and 
all,  in  a  paper  entitled  "  Des  greftes  dermo-epidermiques,  et  en  particulier  des  larges 
lambeaux  dermo-epidermiques,"1  taking  up  the  same  texts.  In  a  discussion  upon  the 
subject,8  participated  in  by  Letievant  and  others,  the  former  says,  speaking  of  animal 
grafts,  "  I  call  these  grafts  zoo-epidermic,  in  opposition  to  human  grafts  which  I  dis- 
tinguish under  the  name  auto-epidermic  or  hetero-epidermic,  according  as  the  grafts  are 
gathered  from  the  subject  grafted  or  from  his  neighbors."  Then  the  means  employed 
to  secure  the  grafts  are  referred  to,  the  lancet  of  Reverdin,  the  scissors  of  Pollock,  the 
cataract-knife  of  Oilier — all  effecting  the  lifting  of  the  epidermis  and  of  the  superficial 
layer  of  the  dermis.  But  even  with  the  weight  of  testimony  in  its  favor,  Letievant 
felt  called  upon  to  appose  the  remark  "  that  the  practice  of  skin  grafting  should  be 
rejected  as  hurtful,  and  that  it  led  to  neglect  of  the  important  indications  of  the  treat- 
ment of  wounds,"  and  at  the  same  time  undertook  the  defence  of  zoo-epidermic  grafts, 
from  the  dog  for  example,  because  auto-grafts  were  painful,  and  caused  new  wounds  in 
the  patient.  M.  Christot  promptly  denied  that  he  had  declared  grafting  to  be  useless, 
but  did  not  avow  himself  a  partisan  of  the  process;  and  with  this  denial  further  oppo- 
sition to  skin  grafting  seems  to  have  ceased. 

We  have  presented  with  some  liberality  the  views  of  Reverdin  with  regard 
to  the  process  of  his  inventing,  frequently  quoting  his  own  words.  It  is  here 
interesting  to  compare  or  contrast  the  ideas  entertained  by  Poncet  with  those 
of  the  master,  following  upon  the  discovery  of  Reverdin,  although  antedating 
in  publication  the  formulized  expressions  of  the  latter. 

At  the  end  of  the  discussion  just  referred  to,  Poncet3  took  occasion  to  recommend 
the  practice  of  Oilier  in  the  employment  of  large  and  numerous  grafts,  stating  at  the 
same  time  that  he  had  failed  with  epithelial  grafts  alone  ;  and  continuing  his  discourse 
he  goes  on  to  say  that  "as  to  the  proliferation  of  the  epithelial  elements,  it  is  a  simple 
action  of  the  presence  of  the  mucous  layer  of  the  epidermis,  determining  at  times  the 
epithelial  transformation  of  the  elements  of  the  embryonal  tissue,  to  which  it  is  united. 
.  .  .  In  the  seam  of  junction  of  the  granulations  with  the  morsel  transplanted,  the 
same  phenomena  are  observed  as  in  the  union  of  the  margins  of  a  wound  by  first 
intention.  The  extension  of  the  graft  has  not  seemed  to  us  to  be  owing  to  a  prolifera- 
tion of  the  mucous  layer.  It  must  act  by  its  presence  upon  the  embryonal  elements 
directly  in  relation  with  its  margins,  and  thus  determine  their  epidermic  transformation." 
In  the  same  connection  we  refer  to  the  opinions  already  advanced  by  Reverdin,  and  we 
propose  to  adduce  those  of  Coste,  as  expressed  in  a  conference  upon  epidermic  grafting 
held  on  the  31st  of  May,  1873,  at  the  Ecole  de  Medecine.*  "  How,"  asks  the  distin- 
guished professor,  "  is  the  adhesion  brought  about  ?  How  is  proliferation  accomplished  ? 
That  is  very  simple.  The  transplanted  epidermis  determines  by  its  presence,  by  its 
contact,  the  transformation  of  the  embryonal  cells  of  the  granulations  into  epidermic 
cells.  This,  according  to  Reverdin,  Colrat,  and  Poncet  (de  Lyon),  is  the  most  probable, 
and  even  the  only  possible  theory." 

On  the  other  hand  Mr.  Bryant  gives  utterance  to  a  directly  opposite  doctrine.  In 
notes  from  the  Wards  of  the  Cork  Hospital,5  communicated  by  Mr.  Martin  Howard, 
we  find  the  following:  "  The  question  was  asked  whether  the  skin  graft  was  an  excitor 
of  skin  action,  or  were  the  cells  proliferated  ?  Mr.  Bryant  declared  that  the  grafts  grew, 
the  skin  being  prolonged  from  the  graft,  and  that  the  border  also  threw  out  a  growth. 
This  he  proved  in  the  following  ingenious  way.  He  had  a  white  man  under  his  care, 
suffering  from  an  ulcer  on  his  leg,  and  on  this  ulcer  he  grafted  a  portion  of  the  skin 
taken  from  a  negro  in  the  hospital.  As  the  ulcer  decreased  in  size,  the  piece  of  black 
skin  increased  considerably."  However  satisfactory  this  experiment  may  have  been, 
the  observation  is  at  variance  with  those  of  Reverdin  and  of  Coste,  the  latter  of  whom 
expressly  declares6  that  "  grafts  borrowed  or  obtained  from  a  negro  and  implanted  upon 
a  white  person,  rapidly  lose  color  and  bleach  out  entirely,  from  the  effect  of  the  pro- 
gressive absorption  of  pigment.     "  I  saw,"  says  this  author,  "  a  remarkable  example  of 

'  Lyon  Medical,  t.  viii.  p.  494,  1871.  *  Ibid.,  p.  520.  s  Lyon  Med.,  p.  564. 

4  Marseille  Medical,  lOe  annee,  No.  7,  Juillet,  1873. 

6  Dublin  Journ.  of  Med.  Science,  vol.  lxi.  p.  388.  6  Loc.  cit.,  p.  398. 


544  PLASTIC    SURGERY. 

this,  a  few  months  ago,  at  the  Hotel  Dieu,  in  Paris.  Besides  which  I  note  the  rarity 
of  pigment  in  cicatricial  epidermis."  M.  Coste  finds  it  necessary  to  preface  his  remarks 
with  the  observation  that  "  in  spite  of  the  identity  of  terms,  the  animal  graft  bears  no 
resemblance,  either  in  its  course  or  in  its  definitive  evolution,  to  tlie  vegetable  graft ;  a 
radical  difference  separates  the  two.  What,"  asks  the  professor,  "  is  a  vegetable  graft? 
It  is  an  individual,  or  a  part  of  an  individual,  transplanted  upon  another  individual, 
which  in  some  way  serves  as  a  soil  for  it.  In  this  soil  it  lives  as  a  parasite,  the  trans- 
ported individual  develops  and  lives  a  life  which  is  its  own,  meanwhile  preserving  its 
autonomy,  its  individuality.  It  is  quite  different,  in  the  double  point  of  view  of  theory 
and  practice,  with  regard  to  the  animal  graft.  This,  borrowed  from  the  individual 
himself  or  from  another,  has  essentially  for  its  object  the  filling  up  of  a  loss  of  substance. 
The  borrowed  part  and  that  to  which  it  is  united,  after  reciprocal  modifications  and 
influences,  coalesce,  the  one  with  the  other  ;  they  end  by  becoming  confounded,  by  being 
identical,  by  living  a  common  life.  There  is,  therefore,  no  analogy  between  the  animal 
graft  and  the  vegetable  graft ;  these  two  grafts  resemble  each  other  in  name  only."  We 
will  not  follow  Coste  further,  but  merely  state  that  he  reviews  the  experiments  of  Bert, 
especially  the  "  greffe  Siamoise"  of  that  observer,  the  "rat  sur  rat,"  which  tests  his 
own  views  upon  the  same  subject. 

Again,  in  1872,  M.  Reverdin  insisted  upon  the  manner  of  adherence  of  the  grafts, 
and  of  their  effect  on  granulating  surfaces — for  he  laid  his  grafts  upon  the  surface — and 
declared1  that  he  saw  grafts  from  the  negro,  or  black  cat,  lose  color  and  become  alto- 
gether white.  And  in  a  note  upon  epidermic  grafting,  presented  by  M.  Claude  Ber- 
nard to  the  Academy  of  Sciences,  at  the  meeting  of  November  27,  of  *the  same  year, 
Reverdin  says:  "There  results  from  this  histological  examination  (1)  that  the  adher- 
ence of  the  graft  is  effected,  in  the  first  place  by  the  epidermis,  and  only  secondarily 
by  the  dermis  ;  (2)  that  the  epidermis  acts  by  action  of  contact  (catabiotic  action, 
Gubler),  in  determining  the  transformation  of  embryonal  elements  into  epidermis."  In 
the  same  volume,  page  326,  may  be  found  a  note  of  M.  Oilier,  presented  by  M.  Claude 
Bernard  at  the  meeting  of  March  18,  containing  the  following,  bearing  upon  the  sub- 
ject before  us,  namely,  the  aim  and  action  of  the  transplanted  or  transported  germs  : 
"As  for  myself,  in  transporting  large  cutaneous  morsels  I  seek  to  reduce,  as  much  as 
possible,  the  natural  epidermization  of  the  granulations.  My  aim  is  to  change,  upon  a 
more  or  less  extensive  surface  of  the  wound,  the  process  of  repair.  I  replace  the  epi- 
thelial layer  of  new  formation  with  a  cutaneous,  fleshy,  thick  layer,  stable  in  its  funda- 
mental elements,  and  destined  to  fill  the  role  of  a  true  skin.  It  is,  therefore,  an  auto- 
plasty  which  I  perform." 

AY  Idle  not  attempting  a  complete  history  of  skin  grafting,  I  have  never- 
theless followed  the  idea  from  mind  to  mind,  and  developed,  although  not  at 
great  length,  the  opinions  entertained  by  the  originator  himself,  as  well  as  by 
those  of  his  countrymen  who  stood,  so  to  speak,  around  him,  concerning  the 
part  performed  by  the  germs  transported  and  transplanted.  The  preponder- 
ance of  testimony  seems  to  weigh  in  favor  of  the  view  that  the  epithelial 
germs  grow  in  or  upon  their  new  soil,  but  that  a  more  remarkable  phe- 
nomenon, to  be  observed  after  the  transfer,  is  to  be  found  in  the  influence 
which  they  exert  in  determining  by  their  presence  and  contact  the  trans- 
formation of  the  embryonal  cells  of  the  granulations  into  epidermic  cells. 
And  this  | lower  docs  not  appear  to  be  limited  to  the  immediate  neighborhood 
of  the  grafts,  but  seems  to  be  communicated  to  the  sluggish  borders  of  the 
wound  or  ulcer. 

Reverdin  presented  his  first  case  and  announced  his  discovery  on  the  8th  of 
December,  1869.  In  England,  the  value  of  " epithelial  grafting"  was  at  once 
appreciated,  and  as  early  as  May,  1870,  Mr.  G.  I).  Pollock,  of  London,  had 
put  keverdin's  method  in  practice,  and  had  tested  it  in  four  cases,  which, 
with  a  number  of  others,  were  made  the  subject  of  a  paper  entitled  "Cases  of 
Skin  grafting  and  Skin  Transplantation,"  read  on  November  11,  1870,  and 

1  Bulletin  de  Therapeutique,  t.  lxxxiii.  p.  71,  1872. 


SKIN    GRAFTING.  545 

published  in  the  Transactions  of  the  Clinical  Society  of  London,  for  the  year 
1871.  At  first  he  made  a  slight  incision  in  the  granulations,  and  imbedded 
the  piece  of  skin;  but  afterwards  he  followed  Reverdin  closely,  laying  the 
graft  on  the  granulations,  or  surface  of  the  ulcer.  lie  found  no  difference  in 
the  results  ;  but  he  ascertained  it  to  be  essential  that  the  patient  should  be  in 
e;ood  health — a  condition  which  appeared  to  lie  at  the  foundation  of  success. 
With  regard  to  the  process  of  cicatrization  itself,  I  prefer  to  adduce  the 
words  of  the  author,  for  it  will  be  observed  that,  while  agreeing  to  some 
extent  with  Bryant,  already  quoted,  in  his  explanation  of  the  phenomena 
occurring  after,  or  induced  by,  grafting,  he  differs  altogether  from  Reverdin, 
Coste,  Poncet,  and  other  French  authorities,  and,  in  differing,  presents  some 
new  features  in  the  case. 

"When,  as  Pollock  expresses  himself,  a  graft  is  successful,  there  appears  a  fine,  thin, 
delicate  membrane,  and  in  this  membrane  may  be  seen  a  beautiful  network  of  red  ves- 
sels. Shortly  the  membrane  becomes  white,  and  the  vessels  disappear.  "  The  mem- 
brane is,  as  far  as  I  can  judge,  the  deeper  layer  of  epithelial  cells  which  possessed  the 
greatest  amount  of  vitality  and  youth."  And,  he  adds  further  on,  the  wave  of  new  pel- 
licle stimulates  the  margin  of  the  original  ulcer,  and  induces  cicatrization.  Mr.  Pollock's 
first  case  was  that  of  a  child  of  eight  years,  who,  her  dress  taking  fire,  was  burned  in 
both  thighs.  The  left  had  healed  at  the  time  of  her  admission  into  St.  George's  Hos- 
pital, but  the  right  thigh  presented  an  ulcer  extending  from  above  the  trochanter  down 
to  the  outer  surface  of  the  knee.  On  the  5th  of  May,  the  grafting  was  done,  and  on  the 
26th  of  November,  of  the  same  year,  the  healing  was  complete.  In  the  second  case 
there  were  two  ulcers ;  in  the  third,  a  chronic  ulcer  of  the  right  leg ;  the  fourth  was 
one  of  ulcer  over  the  tibia,  from  a  kick  ;  the  fifth  one  of  chronic  ulcer  of  the  leg ;  the 
sixth,  a  case  of  large  sore  on  the  chest,  from  a  burn  ;  the  seventh,  eighth,  ninth, 
eleventh,  twelfth,  and  fourteenth,  cases  of  ulcer  of  the  leg;  the  tenth,  one  of  scrofulous 
ulcer  of  the  forearm ;  the  thirteenth,  one  of  contraction  after  a  burn,  in  which,  after 
dividing  the  cicatricial  bands,  the  gap  was  grafted,  no  success  following  the  operation  ; 
and  the  fifteenth  and  sixteenth,  cases  of  syphilitic  ulcer,  in  both  of  which  the  process 
proved  a  failure. 

The  practice  of  skin  grafting  soon  found  favor  in  England,  in  spite  of 
misgivings  more  or  less  distinctly  expressed,  and  cases  were  presented  to 
various  medical  societies.  Among  the  many,  we  may  refer  to  the  cases  of 
Mr.  Pearse,1  in  his  account  of  which  the  author  advocated  the  employment 
of  small  pieces,  and  making  a  wide  gap ;  and  to  that  of  Mr.  Raven,2  who 
supplemented  insutficient  grafts  from  a  little  girl,  with  "zoo-epidermieal" 
grafts  from  a  young  pig. 

The  method  was  adopted  in  Germany,  in  which  country  Dieffenbach  had 
given  such  development  to  plastic  surgery ;  into  Italy  it  speedily  found  its 
way ;  in  Spain,  and  other  European  countries,  it  became  the  accepted 
innovation,  as,  for  example,  in  Constantinople,  in  which  city  Zebrowski 
published,  in  18T3,3  an  essay  upon  skin  grafting — "Sur  la  grefte  epider- 
mique" — basing  it  on  observations  made  upon  eight  successful  cases.  In 
fact,  to  use  the  language  of  Martin  Howard,4  in  his  communication  already 
referred  to,  "In  the  journals  will  the  work  of  the  grafters  be  found;"'  an 
evidence  of  the  lively  zeal  with  which  the  profession  tested  and  approved  of 
the  practice. 

It  will  presently  be  seen  that  skin  grafting  became  immediately  active  in 
America,  reaching  almost  synchronously  the  United  States,  Canada,  and 
Mexico  ;  but  we  prefer,  in  order  to  preserve  the  autonomy  of  the  subject.  t>> 
revert  to  the  two  questions  which  arose  in  the  country  of  its  origination,  and 
which  have  an  important  bearing  both  upon  the  theory  and  the  practice  of 

1  Practitioner,  vol.  viii.  p.  36-39.     London,  1872.  *  Loc.  cit..  1S77. 

Gaz.  med.  d'Orient,  t.  xvi.  pp.  136,  137.  *  Loc.  cit.,  p.  3^6. 

VOL.  I. — 35 


546  PLASTIC    SURGERY. 

the  operation.  The  first  of  these  refers  to  the  persistence  of  vitality  in  the 
grafts ;  and  the  second  to  the  size  of  the  particles  or  pieces  translated  ;  ques- 
tions which,  as  may  be  supposed,  commanded  the  attention,  not  of  French 
observers  only,  but  also  of  those  of  other  countries,  without  excluding  the 
members  of  the  medical  profession  in  the  United  States.  Not  that  these 
questions  were  absolutely  disposed  of  in  France,  but  that  they  were  presented 
in  a  very  formal  manner  in  several  papers  of  note. 

The  first  of  these,  by  Paul  Bert,  antedated  skin  grafting,  so  called,  and  had  for  its 
title  "  Experiments  and  reflexions  upon  animal  grafting,"1  and  entertained  the  proposition 
"  of  the  preservation  of  vital  properties  in  parts  separated  from  the  body  ;"  and  declared 
that  "transfusion  of  blood,  animal  grafting,  restoration,  constitute  but  one  single  and 
immense  order  of  facts,  which  are  properly  studied  simultaneously,  and  which  might 
be  comprehended  under  one  common  formula."  Then  follow  his  divisions,  (1)  animal 
graft  ;  (2)  "  marcotte,"  by  slips  or  shoots  ;  and  (3),  grafting  by  approximation  of  ani- 
mals of  different  species.  Under  marcotte,  Bert  ranges  the  "  Indian  method,  in  which 
the  flap  is  never  for  a  moment  separated  from  the  body."  It  will  be  observed  that  Bert 
treats  of  anaplasty  and  autoplasty,  and  the  same  may  almost  be  said  of  Oilier,2  of  Lyons, 
who,  at  a  later  period,  discussed  the  whole  subject  of  animal  grafts,  giving  preference 
to  larger  pieces  instead  of  the  minute  morsels  recommended  by  Reverdin,  approaching 
the  boldness,  but  not  quite  equalling  the  venture,  of  Hamilton,  of  New  York.  Paul 
Bert's  remarkable  experiments  in  animal  grafting3  gave  as  results  the  following;  of  less 
value  from  the  fact  of  the  adhesion  of  the  tails  of  rats,  than  from  the  length  of  time 
which  had  elapsed  since  their  amputation  before  they  were  applied  to  a  stump.  Thus 
tails  of  rats,  separated  from  the  animal  for  3^  hours,  adhered  when  grafted,  and  so  did 
others  after  a  lapse  of  7-|>  16,  26,  48,  62,  64,  and  72  hours,  although  failure  ensued  in 
other  cases.  And  Oilier4  adduced  instances  of  periosteal  flaps  24  hours  old,  obtained 
from  a  rabbit,  which  adhered  when  applied  to  another  animal  of  the  same  species. 

Georges  Martin,  in  his  Thesis  already  referred  to,  upon  the  duration  of  the  vitality  of 
tissues,  etc.,  brings  together  343  grafting  operations,  which  form  the  object  of  60  per- 
sonal observations,  and,  in  detailing  these,  records  very  surprising  experiments  and  their 
results ;  and  he  quotes  Baronio,  Gohier,  Wiesmann,  Dieffenbach  and  others,  and  their 
variable  success.  But  the  most  worthy  of  attention  are  his  original  experiments  and 
observations,  as  to  the  limits  of  vitality,  with  cutaneous  and  dermo-epidermic  grafts  in 
the  human  subject.  It  would  appear  that  none  of  his  grafts  lived  and  were  effective 
after  108  hours'  exposure  "in  free  air"  at  a  temperature  of  nearly  zero,  C.  [32°  F.j, 
but  that  when  kept  in  tubes,  or  confined  air,  under  the  same  circumstances,  the  grafts 
were  successful.  Another  experiment,  the  temperature  being  nearly  at  zero,  C,  was 
successful  after  96  hours,  the  morsel  having  been  preserved  in  free  air ;  in  another,  the 
temperature  being  6°  C.  [42°. 8  F.],  the  limits  were  82  and  96  hours,  under  the  re- 
spective conditions  of  free  and  confined  air;  when  the  temperature  was  12°  C.  [53°. 6 
F.]  they  were  72  and  84  hours;  when  15°  C.  [59°  F.]  the  figures  were  60  and  72; 
when  20°  C.  [68°  F.],  they  were  36  and  36  ;  and,  finally,  a  last  experiment,  at  28°  C. 
[82. °4  F.],  showed  the  limits  of  vitality  to  be  6  hours  and  7  hours,  in  free  and  in  con- 
fined air  respectively. 

M.  Martin  laments  that  we  have  no  medicament  capable*of  prolonging  cellular  life, 
but  he  asks  the  question,  whether  certain  alkaline  solutions  may  not  afford  the  means. 
In  this  connection  he  quotes  M.  Caliste,  as  having  proved  that  muscular  irritability 
continues  for  a  long  time  in  a  weak  solution  of  potassa,  while  distilled  water  destroys 
it,  rapidly,  and  M.  Pelikan,  who  saw  frogs'  muscles,  plunged  in  these  solutions,  remain 
intact  after  fourteen  days.  Finally,  M.  Brown-Sequard  noticed  contractility  of  the  iris 
fur  sixteen  days,  and  accounted  for  the  phenomenon  by  the  residence  of  the  membrane 
in  the  alkaline  media  of  the  eye.     Besides  the  conditions  referred  to  as  favoring  adhe- 

'  .Touni.il  <le  l'Anat.  et  de  la  Physiol,  normale  et  patliol.  do  l'homme  et  des  animaux,  t.  i.  pp. 
69-87.     Paris,  18G4. 

2  Bullet,  de  I'Acad.  de  Medecine,  t.  i.  2o  serin,  pp.  242-24G.  Paris,  1872.  "  Sur  les  greffes 
entailer's  ou  autoplastiques." 

3  These,  1863.     See  also  Cost.',  Marseille  Medical,  1873. 

4  Traito  sur  la  regeneration  dus  os,  t.  i.  p.  417. 


SKIN   GRAFTING.  547 

sion  of  the  grafts,  or  "  success"  as  M.  Martin  calls  it,  he  declares  that  "  longevity  is  in- 
versely as  the  mass."  Of  course,  the  conditions  of  the  persistence  of  the  life  of  the 
graft  receive  careful  attention,  and  temperature,  hygrometrical  state,  and  volume,  are 
referred  to  as  the  agents  which  chiefly  influence  its  duration.  Cold,  says  M.  Oilier, 
favors  the  success  of  transplantation  ;  and  "elevation  of  temperature,"  in  the  language 
of  Bert,  "  is  one  cause  of  a  shorter  duration  of  vitality."  Moisture  hurries  decomposi- 
tion ;  and  smaller  masses  live  longer  than  the  larger.  And,  finally,  the  hit  of  living 
tissue  to  be  preserved  must  be  maintained  at  a  low  temperature,  and  in  a  vessel  her- 
metically closed.  Among  the  conclusions  reached  by  M.  Martin,  we  may  give  promi- 
nence to  the  following,  which  bears  upon  large  and  small  grafting  alike  ;  "  a  separated 
part  preserves  its  vitality  for  several  days,  during  which  it  is  apt  to  contract  adherence." 
"The  surgeon,  therefore,  will  always  be  called  in  time  to  replace  an  organ  ;  besides,  he 
may  employ  for  the  reconstruction  of  a  separated  organ  a  bit  of  tissue  some  time  re- 
moved." So  that,  in  preparation  for  a  plastic  operation,  "  tissues  may  be  collected 
in  an  amphitheatre  immediately  or  soon  after  death."  It  is  almost  needless  to  add  that 
the  condition  of  the  part  receiving  the  graft,  as  well  as  that  of  the  graft  itself,  must  be 
suitable;  for,  in  order  to  procure  adhesion,  the  mutual  concurrence  of  the  plasmatic  cells 
of  the  piece  transported,  and  of  the  breach,  is  indispensable. 

From  the  foregoing  experiments  we  are  led  to  believe  that  parts  separated 
from  the  body  retain  their  vitality  for  a  very  considerable  time;  and,  grant- 
ing that  the  experiments  could  be  repeated,  the  surgeon  need  rind  no  diffi- 
culty in  appropriating,  as  has  been  done,  flaps  from  amputated  members,  or 
even  borrowing  particles  or  bits  of  tissue  from  the  cadaver. 

As  we  have  already  remarked,  skin  grafting  speedily  had  its  claims  ac- 
knowledged in  America;  indeed  Bemutti1  refers  to  the  statement  of  Spanti- 
gati  as  to  the  communications  of  Reverdin  and  of  Frank  Hamilton,  of  New 
York,  having  been  sent  in  December,  1869,  to  the  Societe  de  Chirurgie,  of 
Paris,  but  adds  that  there  is  in  the  Bulletins  of  that  Society  for  1869,  no 
record  of  Hamilton,  whom  Spantigati  makes  co-author  with  Reverdin.  One 
of  the  earliest  notices  of  skin  grafting  by  a  writer  on  this  continent,  was  con- 
tained in  a  paper,  published  Dec.  12,  1870,  by  Sr.  D.  Luis  Muiioz,  of  Mexico,2 
in  which  the  subject  was  carefully  presented;  and  this  was  followed  by  an- 
other, accompanied  with  four  cases,  by  J.  M.  Bandera,  which  appeared  the 
following  year,  in  the  same  Journal.  In  the  same  year,  1871,  Prof.  J.  T. 
Hodgen  contributed  to  the  St.  Louis  Medical  and  Surgical  Journal3  articles 
upon  "Cell  or  Skin  Grafting,"  giving  cases,  and  explaining  the  methods  of 
procuring  grafts  employed  by  himself.  These  were  three  in  number :  (1)  By 
snipping  off  bits  of  human  skin  and  epithelial  layer;  (2)  by  scratching  oft* 
scales  of  epithelium;  and  (3)  by  removing  sheets  of  detached  portions  of 
epithelium.  And  he  grafted  also  from  parts  stained  with  India  ink,  and 
from  moles.  Hodgen  was  successful  in  his  grafting  ;  but  it  is  remarkable 
that  he  obtained  results  with  pigmentary  grafting  quite  at  variance  with  those 
of  Reverdin,  Coste,  and  others  in  France,  although  he  found  them  in  corre- 
spondence with  those  of  Bryant,  already  referred  to  in  this  article.  The 
American  author  says  that  when  cells  of  the  deep  layer  of  the  epithelium  are 
used,  the  pigment  also  grows  with  the  growth  of  the  graft,  but  that  when 
old  dry  scales  are  grafted,  no  pigmentary  deposit  takes  place.  It  is  curious 
to  contrast  with  the  experience  of  Hodgen  that  of  Maxwell,*  who,  to  fill  a 
gap  produced  in  the  face  by  a  gunshot  wound,  resorted  to  an  anaplastic 
operation,  engrafting  the  skin  of  a  white  man  upon  a  negro  patient,  with 

1  Giorn.  della  Reale  Accad.  di  Medicina  di  Torino,  t.  xxxvii.  pp.  35-55,  1874. 

8  Gaceta  Med.     Mejico,  1870. 

3  St.  Louis  Med.  and  Surg.  Journal,  vol.  viii.  N.  S.,  p.  289,  1871. 

«  Pliila.  Med.  Times,  vol.  iv.  p.  37,  1873. 


548  PLASTIC   SURGERY. 

the  consequence  of  finding,  after  three  months,  that  the  white  skin  had  lost 
its  distinguishing  character,  uand  that  the  whole  surface  of  the  wound  was 
of  uniform  blackness."  Many  experiments  were  subsequently  made,  from 
time  to  time,  in  colored  skin  grafting,  but  we  need  refer  only  to  those  of  J. 
II.  W.  Meyer,  who  reported  two  cases  in  1877.1 

Skin  grafting  was  now  practised  in  all  parts  of  I^orth  America.  In  Canada, 
in  1871,  in  the  proceedings  of  the  Medico-Chirurgical  Society,  of  Montreal,  we 
find  that  Dr.  W.  II.  Hingston  evoked  discussion  upon  a  paper  on  skin  graft- 
ing, accompanied  with  cases.2  In  Baltimore,  Prof.  J.  J.  Chisolm3  practised 
skin  grafting  publicly,  and  advocated  the  employment  of  grafts  obtained  from 
the  deeper  parts ;  in  California,  Prof.  II.  W.  Toland  recorded  a  case  of  skin 
grafting  practised  by  him  in  1873  ;4  and  in  1874,  Prof.  D.  Hayes  Agnew,6  of 
Philadelphia,  published  cases  and  remarks  upon  ulcers  and  skin  grafting, 
reported  favorably  upon  the  process,  and  proposed  to  supply  skin  from  a 
portion  of  the  body  corresponding  to  the  diseased  part,  as  promising  more 
success. 

It  were  invidious,  almost,  to  withhold  the  names  of  the  surgeons  who  made 
early  application  of  the  new  process  of  inducing  cicatrization,  but  the  limits 
of  this  article  forbid  the  enumeration.  We  may,  however,  refer  to  Dr.  How- 
ard's6 investigation  of  "muscle  grafting,"  which  he  believed  to  disprove  the 
"  epithelium  theory ;"  to  Dr.  M.  Donnelly's7  paper,  with  cases,  on  skin  grafting 
as  practised  in  St.  Vincent's  Hospital ;  to  that  of  Dr.  W.  F.  Cheney,8  with 
cases,  in  1872  ;  to  the  paper  aud  cases  of  Dr.  E.  L.  Wemple9  in  1873  ;  to  the 
contribution  of  Dr.  J.  W.  Trader,10  in  the  Medical  Archives  of  St.  Louis,  re- 
lating to  a  railroad  injury  in  which,  after  sloughing  of  the  crushed  foot,  skin 
grafting  was  happily  resorted  to ;  to  the  Bellevue  Hospital  report,11  in  1873, 
of  the  method  of  setting  grafts,  referring  to  the  setting  of  two  thousand 
grafts ;  to  a  case  of  Dr.  B.  M.  Cromwell,12  with  comments,  reported  in  1875  ; 
and  finally  to  Prof.  S.  G.  Maclean's  successful  treatment  of  a  large  ulcer  by 
simple  measures  and  skin  grafting. 

Before  concluding  this  article,  I  purpose  to  briefly  review  the  opinions 
entertained  with  regard  to  the  preferable  size  of  the  grafts,  and  begin  by 
stating,  on  his  own  authority,  that  Reverdin  always  adhered  to  the  small 
grafts  with  which  he  inaugurated  his  system,  and  that  Mr.  Pollock  was,  in  the 
main,  likewise  minded.  Nevertheless,  we  find  M.  Oilier,13  in  1872,  saying 
that,  instead  of  grafts,  little  morsels  of  two,  three,  or  four  millimetres  square 
are  preferably  used,  "  as  is  practised  by  M.  Reverdin."  And  further  on,  Oilier 
adduces  his  favorable  experiences  with  grafts  of  large  size,  of  four,  six,  or  eie;ht 
square  centimetres,  involving  the  entire  dermis,  and  constituting  "a  veritable 
autoplasty;"  and  expatiates  upon  the  necessity  of  immobility  in  the  parts  sub- 
mitted to"  operation,  adding  that  this  is  best  secured  by  a  silicated  apparatus. 
At  first  he  employed  epidermic  grafts,  then  dermo-epidermic  grafts  of  one  or 
two  centimetres'  extent,  and  finally  grafts  of  skin  and  cellular  tissue;  all  in 
one  patient,  to  procure  cicatrization  after  a  large  burn.     lie  observed,  how- 

1  Chicago  Med.  Journal  and  Examiner,  vol.  xxxiv.  p.  320,  3877. 

2  Canada  Med.  Journal,  vol.  vii.  p.  495.     Montreal,  1871. 

3  Richmond  and  Louisville  Med.  Journal,  vol.  x.  p.  353,  1870. 

4  Western  Lancet,  1874.  6  Med.  and  Surgical  Reporter,  Nov.  1S74. 

6  New  York  Med.  Journal,  Sept.  1871.  7  New  York  Med.  Record,  vol.  vii.  p.  572,  1872. 

8  Trans.  Mod.  Society  of  California,  1872,  pp.  106,  108. 

p  Pacific  Mod.  and  Surgical  Journal,  vol.  vii.  p.  381,  1873-4. 

'°  Med*  Archives,  vol.  vi.  p.  257,  1871. 

"   New  York  Mod.  Record,  vol.  viii.  p.  538,  1873. 

12  Atlanta  Med.  and  Surgical  Journal,  vol.  xiii.  p.  641,  1875-6. 

1:1  Bullet,  do  l'Acad.  de  M6d.     Paris.  1872.     2e  serie,  pp.  244,  246. 


SKIN    GRAFTING.  549 

ever,  that  after  four,  five,  or  six  days  the  epidermis  fell  away,  and  left  the 
graft  bare  as  if  it  had  been  blistered;  and  concluded,  from  what  had  occurred, 
that  "perhaps  grafts,  called  epidermic, succeed  only  when  containing  a  lamella 
of  dermis."  And  that  these  procedures  were  successful,  may  be  inferred  from 
the  fact  that,  in  1873,  Poneet  gave  in  the  Lyon  Midical1  an  account  of  the 
"presentation  of  a  patient  bearing  autoplastic  cutaneous  grafts  introduced  a 
year  before  by  M.  Oilier."  In  America  also,  in  1872,  Dr.  M.  Donnelly,  in  a 
paper  already  referred  to,  advocated  the  use  of  grafts  as  large  as  a  quarter  of 
an  inch,  claiming  such  to  be  superior  to  smaller  ones;  and  declared  that  he 
regarded  the  source  of  supply  as  indifferent,  except  that  the  graft  should  be 
taken  from  a  point  of  least  motion,  as  the  insertion  of  the  deltoid. 

In  conclusion,  we  may  summarize  what  is  known  as  to  skin  grafting  as  fol- 
lows:— 

I.  It  affords  an  admirable  means  of  accelerating  and  facilitating  cicatriza- 
tion. 

II.  The  pellicle  produced  by  its  aid  is  less  prone  to  contraction,  and  con- 
tracts less  than  an  ordinary  cicatrix. 

III.  The  deeper  layer  of  the  epidermic  elements  are  the  chief  factors  of 
growth. 

IV.  The  growing  cicatrix  is  formed  at  the  expense  of  the  embryonal  cells 
of  the  granulating  surface,  stimulated  into  activity  by  the  presence  of  the 
living  cells  of  the  graft. 

V.  This  stimulus,  first  showing  energy  in  and  around  central  islands  of 
new  growth,  induces  similar  activity  at  the  hitherto  dormant  margin  of  the 
ulcer. 

VI.  Grafts  may  retain  vitality  and  be  effective  long  after  separation  from 
the  body. 

VII.  Small  grafts,  of  the  size  of  millet  seeds,  for  example,  are,  in  general, 
preferable  to  larger  ones  ;  although  larger  grafts,  as  of  one-fourth  inch  square 
(Donnelly),  or  even  eight  square  centimetres  (Oilier),  have  had  their  advocates 
and  successes. 

VIII.  Grafts  should  be  obtained  from  the  patient  himself,  if  possible,  but 
in  all  cases  the  danger  of  specific  inoculation  ought  to  be  present  in  the  mind 
of  the  surgeon  who  borrows  grafts  from  one  subject  for  application  upon 
another,  or  who  practises  heteroplasty. 

IX.  Grafts  furnished  by  the  aged  are  less  disposed  to  adhere  than  those 
procured  from  the  young,  and  oftentimes  fail  entirely. 

X.  Grafts  obtained  from  one  race  of  men  may  be  successfully  used  on  indi- 
viduals of  another  race;  and  animal  grafts  may  be  transplanted  upon  human 
beings,  adhere,  and  provoke  cicatrization. 

XL  Foul  surfaces,  or  those  of  persons  in  bad  health,  will  refuse  to  accept 
good  grafts ;  but  with  improvement  or  establishment  <  >f  the  health  of  the  indi- 
vidual bearing  an  ulcer,  and  the  appearance  of  healthy  granulations,  a 
favorable  result  of  skin  grafting  may  be  anticipated. 

XII.  Finally,  the  great  benefits  accruing  from  successful^skin  grafting  far 
outweigh  its  drawbacks,  which  are  the  pain  of  the  operation,  and,  unless 
amputated  limbs  be  utilized,  the  consecutive  pain  in  the  parts  yielding  the 
grafts,  whether,  of  course,  these  be  autoplastic  or  heteroplastic. 

Note. The  author  desires  to  express  his  acknowledgments  to  Surgeon  J.  S.  Billings.  U.  S.  A., 

for  his  personal  kindness  in  the  matter  of  collecting  authorities,  and  through  him  to  the  Library 
of  the  Surgeon-General's  Office,  for  the  invaluable  aid  which  it  has  afforded. 


»  Lyon  Medical,  t.  xir.  p.  293,  1S73. 


AMPUTATIONS. 


BY 


JOHN  ASHHURST,  Jr.,  M.D., 

PROFESSOR  OF  CLINICAL  SURGERY  IN  THE  UNIVERSITY  OF  PENNSYLVANIA,  PHILADELPHIA. 


The  word  Amputation,  from  the  Latin  am-  or  ambi-  (Greek  d^<j>i),  signifying 
"around,"  or  "round-about,"  and  puto,  from  the  root  pu  (to  cleanse)  signi- 
fying to  "  clean"  or  "  cleanse,"  and  particularly  to  "  trim"  or  "  prune"  trees 
or  vines,  from  its  etymological  meaning  might  properly  be  applied  to  any 
operation  the  object  of  which  was  to  remove  an  offending  part  from  the  rest 
of  the  body,  and  thus  might  be  made  to  include  such  diverse  procedures  as 
the  removal  of  tumors,  the  excision  of  joints,  and  the  extraction  of  cataract, 
as  well  as  the  dismemberments,  partial  or  complete,  to  which  it  is  now 
habitually  limited.  Indeed,  it  was  not  uncommon,  a  few  years  ago,  for  sur- 
geons to  refer  to  the  operation  for  removal  of  the  female  breast,  as  an  ampu- 
tation of  that  part,  and  we  still  speak  of  amputations  of  the  penis  and  of  the 
cervix  uteri ;  but,  with  these  exceptions,  the  term  is  now  confined  to  opera- 
tions for  removing  the  whole  or  part  of  one  of  the  limbs,  and,  when  we  read 
or  speak  of  "an  amputation,"  we  understand  that  the  taking  away  of  a  part 
or  the  whole  of  either  the  upper  or  the  lower  extremity  is  referred  to,  and 
that  the  operation  has,  as  far  as  it  has  gone,  been  a  total  removal,  sparing 
nothing  beyond  the  line  of  section. 

Amputation,  the  "  last  resource  of  surgery,"  as  Velpeau  called  it,  is  often 
spoken  of  by  the  public,  and  even  by  some  unthinking  physicians,  as  the 
opprobrium  of  our  art;  and  it  is  said,  very  justly,  that  to  have  saved  one  limb 
is  more  credit  to  the  surgeon  than  to  have  removed,  no  matter  how  skilfully, 
a  hundred.  It  is  true  that,  in  a  certain  sense,  the  advice  to  a  patient  to  have 
a  limb  amputated,  must  be  regarded  as  a  confession  of  failure — failure,  that 
is,  to  be  able  to  effect  a  cure  by  other  modes  of  treatment ;  but  apart  from 
those  cases  of  supreme  urgency  in  which  the  victim  of  disease  or  injury  is 
called  upon  to  choose  between  mutilation  and  certain  death — when,  as  Vel- 
peau significantly  remarks,  he  will  probably  choose  rather  to  live  with  three 
limbs  than  to  die  with  four — there  may  be  many  circumstances  under  which 
the  surgeon  will  feel  justified  in  recommending,  and  the  patient  will  not 
hesitate  in  accepting,  an  amputation,  which,  though  not  essential  for  the 
preservation  of  his  life,  may  afford  the  only  reasonable  prospect  of  placing 
the  patient  in  a  condition  such  as  to  render  that  life  either  agreeable  to  him- 
self or  useful  to  others.  And  it  may  be  observed  that,  while  on  the  one 
hand  the  improvements  in  modern  surgery  have  removed  from  the  field  of 
amputation  many  cases  in  which  the  operation  would  formerly  have  beer 
considered  imperative,  yet  on  the  other  hand,  since  the  introduction  of  sur- 
gical anaesthesia  and  of  improved  methods  of  treating  wounds,  the  operation 
of  amputation  itself  is  a  much  less  dreadful  one  than  it  was  in  the  early  part 
of  the  present  century,  and  may  therefore  be  properly  resorted  to  in  many 
eases  which  would  formerly  have  been  abandoned  as  hopeless,  and  left  with- 

(551) 


552  AMPUTATIONS. 

out  any  treatment  at  all.  Indeed,  so  far  from  the  operation  of  amputation 
deserving  to  be  spoken  of  in  any  opprobrious  terms,  or  to  be  regarded  as  a 
brutal  procedure,  it  may  well  be  called,  as  it  was  by  some  of  the  older  writers, 
uthe  humane  operation;"  and,  abused  as  it  may  have  been  in  some  instances, 
it  is  doubtful  if  any  other  surgical  manipulation  has  upon  the  whole  afforded 
as  much  relief  from  suffering,  or  saved  as  many  lives. 

Amputations  have  been  variously  classified  by  authors,  but  the  division 
commonly  employed  at  the  present  day,  and  that  which  has  most  practical 
value,  is  into  amputations  in  the  continuity  of  a  limb,  or  through  the  boms  of 
which  it  is  constituted,  and  those  in  the  contiguity,  or  through  the  joints  the 
latter  are  also  called  exarticulations,  or  disarticulations. 


History  of  Amputation. 

The  operation  of  amputation  was  known  to  the  ancients,  but  was  ordi- 
narily limited  to  the  severing  of  gangrenous  portions  of  the  limbs  by  incisions 
through  the  parts  already  dead.  Hippocrates,  who  lived  four  hundred  years 
before  the  Christian  era,  in  his  treatise  on  the  Joints,  speaks  of  gangrene 
resulting  from  occlusion  of  the  bloodvessels,  or  following  fractures,  and  directs 
that  in  the  latter  cases  the  mortified  parts  should  be  allowed  to  drop  off  of 
themselves,  as,  the  bones  having  already  given  way,  the  separation  of  the 
dead  from  the  living  parts  will  occur  quickly  ;  when,  however,  the  bones  are 
entire,  the  portion  which  is  below  the  line  of  blackness  is  to  be  removed  at 
an  articulation,  care  being  taken  not  to  wound  any  part  which  still  maintains 
its  vitality,  lest,  if  the  operation  should  cause  pain,  the  patient  might  faint 
away  or  even  die  in  consequence.1  Celsus,  however,  who  flourished  in  the 
reigns  of  Augustus  and  Tiberius  Ca?sar,  directed  that  when  a  gangrenous 
limb  was  to  be  cut  off,  the  flesh  should  be  divided  with  a  knife  between  the 
living  and  dead  parts,  down  to  the  bone — taking  care  to  avoid  the  articu- 
lation, and  rather  taking  away  some  of  the  healthy  tissue  than  leaving  any 
part  of  that  which  was  diseased ;  when  the  bone  was  reached,  the  healthy 
flesh  was  to  be  pushed  back  from  it,  and  cut  around  the  bone,  so  that  a  part 
of  the  latter  should  be  left  bare;  this  was  next  to  be  divided  with  a  small 
saw,  as  close  as  possible  to  the  adherent  flesh,  the  sawn  edge  of  the  bone 
smoothed  or  polished,  and  the  skin  drawn  down  again  over  it.2  It  is  not 
improbable  that  Celsus  understood  the  use  of  the  ligature  in  amputations,  as 
he  certainly  did  in  cases  of  vessels  wounded  in  their  continuity,  though  he 
gives  no  special  directions  for  the  restraint  of  hemorrhage  either  during  or 
after  the  operation.  It  will  be  observed  that  in  recommending  the  incision 
through  living  tissues,  and  the  section  of  the  bone  at  a  higher  point  than 
that  at  which  the  soft  parts  were  to  be  cut,  this  writer  was  far  in  advance  of 
his  contemporaries,  as  indeed  of  many  of  his  successors,  and  in  the  latter 
particular  actually  anticipated  one  of  the  most  important  improvements  in 
the  manual  procedure  which  has  been  introduced,  or  rather  re-introduced,  in 
comparatively  modern  times.  Galen  (A.  D.  181-200)  repeats  the  advice  of 
Hippocrates  that  no  living  part  should  be  touched  in  an  amputation,  and 
gives  as  a  reason  for  preferring  operations  through  the  joints,  that  the  work 
will  be  done  more  quickly  than  if  the  bones  have  to  be  divided.3 

The  first  attempt  to  prevent  hemorrhage  during  an  amputation  appears  to 
have  been  made  by  Archigenes  (A.  D.  81-117),  who  directed  that  the  vessels 

1  TlipponratiH  opera  omnia,  edit.  cur.  C.  Or.  Kuhn,  t.  iii.  p.  247. 

2  A.  (3.  Celsi  Me&ieinae  lib.  vii.  cap.  xxxiii.     Edit.  L.  Targae,  p.  417. 

3  Claudii  Galeni  opera  omnia,  edit.  cur.  C.  G.  Kuhn,  t.  xviii.  pars  i.  p.  718. 


HISTORY    OF   AMPUTATION.  553 

supplying  the  limb  should  be  tied  or  sewed  as  a  preliminary  measure,  or 
that,  in  some  cases,  a  fillet  should  be  applied  around  the  limb  aa  a  whole;1 
when  the  operation  was  terminated,  this  band  was  to  be  removed,  and  a  hot 
iron  applied  if  there  was  much  bleeding.  Heliodorus,  who  practised  at 
Rome  about  the  same  time  as  Archigenes,  advised  that  an  incision  should 
first  be  made  on  the  side  of  the  limb  which  was  least  muscular;  that  the  bone 
should  be  sawn  through  next ;  and  that  the  section  of  the  thickest  part  of  the 
limb  should  be  kept  until  the  last.2  Paulus  ^Egineta,  who  is  supposed  to 
have  lived  during  the  seventh  century  of  our  era,  also  recommended,  on  the 
authority  of  Leonides,  that  the  section  of  the  part  containing  the  principal 
vessels  should  not  be  made  until  after  the  division  of  the  bone,  and  added 
that  the  soft  parts  should  be  protected  from  contact  of  the  saw  by  means  of 
a  linen  rag  (retractor).3 

Turning  to  the  Arabian  writers  on  surgery,  we  find  that  Avicenna  or  Ibn- 
sina  (A.I).  980-1037)  mentions  the  operation  of  amputation  in  connection 
with  the  general  subject  of  sawing  bones,  but  gives  no  special  directions  as 
to  its  performance.4  Rhases,  or  Razes,  who  flourished  about  a  century  earlier, 
refers  to  the  use  of  a  retractor,  and  in  the  fifteenth  book  of  his  Liber  Contim  ns, 
or  Comprehensive  Book  (a  kind  of  common-place  book  treating  of  all  subjects 
relating  to  medicine),  recommends  extraction  of  the  whole  bone  in  cases  of 
caries  or  "  spina  ventosa.5  Haly  Abbas  (Alee-Ibnool-Abbas),  who  died  at 
the  end  of  the  tenth  century,  also  recommends  the  use  of  a  retractor,  and 
gives  advice  as  to  the  mode  of  making  the  incision  for  amputation,  almost 
identical  with  that  of  Paulus  ^Egineta.6  Albucasis  (Aboo-1-Kasim),  who 
lived  about  a  century  later  than  Avicenna,  gives  similar  directions,  but  adds 
nothing  new  to  the  subject.7  The  surgical  writers  of  the  Middle  Ages,  such 
as  Theodoric,  Bishop  of  Cervia8  (died  A.  D.  1298),  Gui  de  Chauliac,  who 
was  the  papal  physician  between  1340  and  1370,9  and  Leonardus  Bertapalia, 
who  appears  to  have  flourished  in  the  early  part  of  the  fourteenth  century,10 
commonly  contented  themselves  with  copying  or  paraphrasing  the  teachings 
of  their  predecessors.  I  may  conclude  this  brief  sketch  of  the  ancient  doc- 
trines of  amputation  by  quoting  from  a  sixteenth  century  translation  of  Gio- 
vanni di  Vigo,  who  lived  about  A.  D.  1510,  the  following  description  of  the 
operation  in  cases  of  gangrene:  it  will  be  observed  that  while  he  mentions 
the  cloth  to  cover  the  soft  parts,  he  does  not  speak  of  using  it  as  a  retractor. 
The  passage  is  also  interesting  as  containing  one  of  the  early  references  to  the 
induction  of  anaesthesia  by  inhalation. 

"  The  manner  to  cut  the  corrupt  member  is  this  :  First,  ye  must  prove  with  a  provct 
[probe]  howe  the  mortification  of  the  member  goeth,  and  afterwarde  yee  must  cut  the 
member  circle  wise,  in  the  fieshie  and  musculous  part,  and  ye  must  dissever  somewhat 
the  flesh  from  the  bone  in  the  over  part  of  the  member.  And  afterward  cutte  the 
rotten  flesh  from  the  bone  by  peece  meale,  and  cover  the  borders  with  warm  cloutes, 
that  they  bee  not  hurt  by  the  ayre.  Then  ye  must  compasse  about  the  over  parte  with 
your  handes,  and  reduce  the  flesh  circle  wise,  and  sawe  the  bone  as  highe  as  yee  canne, 

•  Archigenis  de  amputandis  partibus,  apud  Oribasii  lib.  de  luxat.  ;  Graecorum  chirurgici  libri, 
etc.  e  collect.  Nicetae,  cura  Ant.  Cocchii.     Florent.,  17f)4,  p.  154. 

2  Heliodori  de  extremis  merabris  abscindendis.     Ibid.  p.  156. 

3  Pauli  iEginetse  Medici  Optimi  lib.  vi.  cap.  lxxxiv.  Edit,  princeps.  Venetiis,  in  sedibus 
Aldi,  etc.,  1528,  fol.  95. 

«  Canonis  lib.  iv.  fen  4,  tract.  4,  cap.  12.  Edit.  Cortaei  et  al.  t.  ii.  p.  172.  Venetiis,  apud 
Juntas,  1595. 

5  Haller,  Bibiliotbeca  chirurgica,  t.  ii.  p.  130. 

6  Haly  Filius  Abbas.  Liber  totius  medicine  necessaria  continens,  etc.,  Pract.  lib.  ix.  cap.  lxv. 
Lugdun.,  1523,  fol.  283. 

1  De  chirurgia,  lib.  ii.  sect,  lxxxvii.     Edit.  cur.  J.  Channing,  Oxon,  177^.  t.  ii.  p.  410. 
8  Chirurgia,  lib.  iii.  cap.  x.  9  Chirurgia,  tract,  vi.  doct.  i.  cap.  viii. 

10  Tract,  de  ossibus,  cap.  ii. 


554  AMPUTATIONS. 

with  a  Sawe  of  sharpe  teeth.  Which  done,  ye  must  cauterise  the  cutte  place,  unto  the 
whole  parte,  and  afterwarde  ye  must  cauterise  the  hone,  and  then  cure  the  Wounde  as 
other  burned  Woundes  be  cured.  And  because  that  some  command  to  attoine  [anoint?] 
the  member  before  incision,  by  application  of  a  medicine  wherein  Opium  entereth,  or 
by  the  smelling  of  a  Spunge  wherein  Opium  is,  that  the  whole  bodie  may  bee  brought 
a  sleepe.  Yee  shall  understand  (the  reverence  saved)  they  enterprise  a  daungerous 
businesse,  for  this  disease  sometimes  chaunceth  of  a  medicine  made  with  Opium,  as 
writers  affirme.  Neverthelesse  the  member  may  be  bound  afore  incision,  in  the  upper 
part,  because  of  ye  course  of  ye  bloud."1 

Although,  as  has  been  seen,  Celsus  clearly  indicated  the  importance  of 
dividing  the  bone  at  a  higher  level  than  the  soft  parts,  his  teaching  in  this 
respect  was  soon  forgotten,  and  we  find,  until  comparatively  recent  times, 
surgeons  of  authority  recommending  that  the  whole  limb  should  be  severed 
at  one  stroke.  Thus  Leonard  Botal,  of  Asti  in  Piedmont,  a  military  surgeon 
of  the  sixteenth  century,  devised  an  instrument  like  powerful  shears,2  by 
which  an  amputation  could  be  effected  by  a  single  blow— an  instrument  de- 
nounced by  Jules  Cloquet3  as  more  worthy  to  have  been  invented  by  a  butcher 
than  by  a  surgeon — and  Purmannus,  of  Brandenburg  and  afterwards  of  Bres- 
lau,  writing  more  than  a  hundred  years  later,  speaks  of  having  seen  amputa- 
tion performed  in  a  similar  manner.  Indeed  in  the  works  of  Scultetus,4  and 
even  of  Heister5  (whose  volumes  formed  the  most  popular  surgical  text-book 
of  the  last  century),  may  be  found  illustrations  of  the  severing  of  parts  of 
the  hand  or  foot  with  powerful  forceps  or  with  chisel  and  mallet.  (Figs. 
99,  100.) 

Fig.  99. 


Amputation  of  a  foot  with  cutting  forceps.     (After  Scultetus.) 

The  use  of  the  ligature,  in  amputations,6  was  first  clearly  taught  by  the 
illustrious  Ambroise  Pare  (A.  D.  1509-1590),  in  the  middle  of  the  sixteenth 

1  The  whole  worke  of  that  famous  chirurgion  Maister  John  Vigo  :  Newly  corrected,  by  men 
skilfull  in  that  Arte.  The  fourth  booke  of  Ulcers,  Chap.  7.  At  London.  Printed  by  Thomas 
East,  L586,  fol.  252. 

2  Dionis,  Cours  d'operations  de  chirurgie,  p.  756.     Paris,  1740. 

3  Dictionnaire  de  medecine,  edit.  1821,  tome  ii.  p.  240. 

4  Armamentarium  chirurgicum.     Tab.  xxvii.  xxviii.  pag.  64,  <5S.    Amst.  1(562. 

6  Institnt.  chirnrgicre,  I'.  ii.  sect.  i.  cap.  xxxiii.  (tab.  xii.  fig.  17).     Amst.  1739, 1. 1.  pag.  491. 

c  The  us.-  of  the  Ligature  for  vssrls  wounded  in  their  continuity  had  been  familiar  to  surgical 
writers  from  tin-  time  of  (Vlsns,  and  was  particularly  referred  to  by  Lanfranc,  an  Italian  surgeon 
who  removed  to  Paris  A.  D.  L295  (Ars  ccrmpleta  totius  chirurgiss.  Tract,  i.  doct.  iii.  cap.  ix.), 
by  (iiii  de  Chauliac  (Chirurgia.  Tract,  iii.  doct.  i.  cap.  iii.)  and  his  follower  and  commentator 
Jean  Taganll  (Institnt.  chirurg.  lib.  ii.  cap.  xii.),  by  Vigo  (Op.  cit.  fol.  135),  and  by  Marianus 
Sanctns  (Compend  Chirurgise.  Tract,  do  ulceribus.  De  Chirurgia  Seriptores,  etc.  [ed.  Conrad 
Gtesner],  Tiguri,  1555,  fol.  161;. 


HISTORY    OF   AMPUTATION. 


555 


century,1  yet  so  little  was  the  merit  of  his  teaching  recognized  that  Fabrieiua 
of  Acquapendente  (A.  D.  1537-1619)2  returned  to  the  old  Hippocratic  doc- 
trine of  cutting  through  dead  parts  only,  while  Fabricius  Hildanus  (A.  D. 
1560-163-i)3  employed  a  red-hot  knife  to  sear  the  vessels  as  they  were  cut, 


Fig.  100. 


Amputation  with  chisel  and  mallet.     (After  Scultetus.     The  original  has  been  closely  followed,  even  to  the  extent 
of  giving  the  patient  five  fingers  and  no  thumb.) 

thinking  this  safer  and  more  expeditious  than  the  application  of  ligatures,  and 
even  Wiseman,  the  "  father  of  English  surgery"  {circa  1676),  though  describ- 
ing Pare's  invention,  preferred  the  use  of  a  "  royal  styptic"  or  the  actual 
cautery.4  Peter  Lowe,5  who  died  in  1612,  thought  the  ligature  "reasonable 
sure,  providing  it  be  quickly  done ;"  but  Cooke,  of  Warwick6  [circa  1675), 
refers  to  Pare  for  a  description  of  the  method  of  "  stitching"  the  vessels,  and 
adds  that  it  "  is  almost  wholly  rejected ;"  while  the  famous  quack  Salmon 
(who  died  in  1700)7  does  not  apparently  think  it  even  worthy  of  mention. 

Next  to  the  introduction  of  the  ligature,  the  most  important  improvement 
in  the  operation  of  amputation  was  the  invention  of  the  tourniquet  or  "gripe- 
stick"  as  it  was  called  by  the  English  translator  of  Le  Clerc.8  In  its  original 
form,  this  instrument,  which  was  also  known  as  the  garrot  or  Spanish  wind- 
lass, seems  to  have  been  devised  about  the  same  time  (1674)  by  Morel,  a 
French  military  surgeon,  during  the  seige  of  Besancon,9  and  by  Young,  of 

1  (Euvres  completes,  ed.  par  J.  F.  Malgaigne.     Tome  ii.  p.  224. 

2  De  chirurgicis  operationibus,  cap.  xcvi.    Opera  chirurgica,  Lugd.  Bat.,  1723,  pag.  628. 

3  Tract,  de  gangrama  et  sphacelo,  cap.  xix.     Opera,  Francofurt.  ad  Mam.,  16S2,  pag.  S13. 

4  Appendix  to  Treatise  on  Gunshot  Wounds,  chap.  ii.  Eight  Chirurgical  Treatises.  Sixth 
edition,  vol.  ii.  p.  225. 

5  A  Discourse  of  the  Whole  Art  of  Chirurgerie.  Third  edition.  London,  1634.  Book  II 1 1., 
chap.  7,  page  93. 

6  Melliticium  chirurgise  :  or  the  Marrow  of  Chirurgery.  Fourth  edition.  London,  16S5.  Part 
IV.  Sect.  II.,  page  203. 

7  Ars  chirurgica.    London,  169S,  Book  I.  chap,  xxxii.  (vol.  i.  p.  92). 

8  The  Compleat  Surgeon.     Fifth  edition.     London,  1714,  page  2S7. 

9  Dictionnaire  des  sciences  nieMicales,  tome  lv.  p.  369. 


556  AMPUTATIONS. 

Plymouth,  in  England,  as  described  in  his  "  Currus  Triumphalis  e  terebintho," 
published  in  1679. x  Morel's  apparatus  consisted  of  a  thick  compress,  which 
was  placed  around  the  limb,  and  surrounded  with  a  cord  or  small  rope, 
under  which  were  slipped  two  short  sticks,  by  twisting  which  the  cord  was 

Fig.  101. 


Morel's  tourniquet.     (After  Dionis.)  Morel's  tourniquet  improved.     "  The  common 

tourniquet."     (After  Heister.) 

drawn  very  tight2  (Fig.  101).  Morel's  tourniquet  was  improved  by  Le  Dran3 
and  other  surgeons  (Fig.  102)  by  placing  an* additional  pad  immediately  over 
the  vessels  and  below  the  circular  compress,  by  using  only  one  stick  for 
twisting  the  cord,  and  by  placing  beneath  this  a  piece  of  paste-board — or, 
according  to  Garengeot,4  of  horn  or  leather  (Fig.  103) — so  as  to  render  the 
pressure  on  the  skin  less  severe,  and  thus  avoid  the  risk  of  sloughing,  which 
sometimes  followed  the  use  of  Morel's  instrument.  But  the  greatest  im- 
provement in  the  tourniquet  was  that  made  in  1718  by  the  illustrious  J.  L. 
Petit5  (Fig.  104) — le  grand  Petit,  as  he  has  been  sometimes  called  to  distin- 
guish him  from  other  less  famous  surgeons  of  the  same  name — and  though, 
with  its  wooden  plates  and  screw,  we  should  think  it  but  a  rude  contrivance, 
it  was  in  all  essential  points  the  same  instrument  as  the  tourniquet  employed 
at  the  present  day. 

As  soon  as  surgeons  had  begun  to  emancipate  themselves  from  the  Hippo- 
cratic  and  Galenic  doctrine  of  cutting  only  dead  tissues,  it  was  natural  that 
they  should  adopt  the  Celsian  method,  and  we  accordingly  find  that  the  circu- 
lar mode  of  amputation  was  practised  at  an  earlier  period  than  any  of  the 
flap  operations.  The  first  important  modification  introduced  into  the  pro- 
cedure  of  Celsus,  was  the  suggestion,  about  the  same  time  and  apparently 
independently  of  each  other,  by  Petit,6  in  France,  and  by  Cheselden,7  in  Eng- 

1  Sharp's  Critical  Enquiry  into  the  present  state  of  Surgery,  page  277.  Second  edition.  Lon- 
don, 1750. 

8  Dionis,  Cours  cooperations  do  chirurgie,  Huitieme  Demonstration,  p.  701.  Paris,  1740. 
Dionis  does  not  mention  Morel's  name,  but  Bays  that  the  tourniquet  was  invented  "a  long  time 
ago,  during  the  seige  of  Besan<;on,"  by  "one  of  the  surgeons  of  the  army;"  and  adds  that  it 
lias  been  used  ever  since. 

3  Trait!  des  operations  <le  chirurgie,  p.  555.     Paris,  1742. 

4  Trait!  des  operations  de  ehirurgie,  tome  iii.  p.  35i).     Paris,  1731. 

6  Trait!  des  maladies  chirurgicales,  etc.,  tome  iii.  p.  131.     Paris,  1790. 

6  Op.  fit.  tome  iii.  p.  13(j. 

7  Notes  to  Le  Dran's  Surgery  (Gataker's  Translation),  London,  1749.  Le  Dran  (Traite  des 
Operations  de  Chirurgie,  p.  555.     Paris,  1742")  describes  the  practice  as  his  own,  but  Cheselden 


HISTORY   OF   AMPUTATION. 


557 


land,  of  the  double  incision  of  the  soft  parts ;  the  skin  and  superficial  fascia 
being  divided  first,  and  retracted,  and  the  muscles  cut  by  a  second  incision  at 
the  highest  point  thus  exposed.  It  is  right  to  add  that,  according  to  Vel- 
peau,  both  of  these  writers  were  anticipated  by  Maggi,  who  is  said  by  the 


Fig  103. 


Fig.  104. 


Application  of  the  common  tourniquet.     (After  Heister.) 


Petit's  tourniquet.     (After  Petit.) 


surgeon  of  "  La  Charite"  to  have  employed  the  double  incision  in  1552.  I 
have,  however,  read  very  carefully  Maggi's  account  of  amputation,  and  can- 
not find  that  he  recommended  a  double  incision,  though  he  directed  that  an 
assistant  should  retract  the  soft  parts  as  much  as  possible,  so  that  the}T  might 
more  readily  be  brought  down  again  to  cover  the  bone.1  Louis2  practically 
returned  to  the  Celsian  method,  dividing  all  the  soft  parts  at  the  same  level, 
but  sawing  the  bone  at  a  higher  point — an  important  feature  of  the  operation, 
the  value  of  which  Petit  and  Cheselden  had  overlooked.  Louis  also  employed 
digital  compression  instead  of  the  tourniquet,  believing  that  the  latter  inter- 
fered with  the  retraction  of  the  muscles.  Valentin3  (1772)  advised  that  the 
position  of  the  limb  should  be  varied  at  different  stages  of  the  operation,  so 
that  the  muscles  of  each  part  should  be  left  as  long  as  possible.  "With  a 
similar  view,  Hey,4  of  Leeds,  in  amputating  the  thigh,  divided  the  posterior 
muscles  at  a  lower  level  than  the  anterior,  in  order  that  their  greater  tendency 
to  retraction  might  thus  be  compensated  for.  To  this  surgeon,  together  with 
Alanson,5  of  Liverpool,  and  Benjamin  Bell,6  of  Edinburgh,  is  due  the  im- 

speaks  of  having  suggested  it  independently  many  years  before.  In  his  account  of  the  famous 
case  of  Samuel  Wood  (avulsion  of  arm  and  scapula),  which,  according  to  Haller,  was  first  ap- 
pended to  the  edition  of  his  "Anatomy  of  the  Human  Body,"  published  in  1741  (1740),  Chesel- 
den refers  to  the  double  incision  as  having  been  introduced  by  himself  "  about  twenty  years 
since"  (Anatomical  Tables,  Tab.  xxxviii.  page  43.  Boston,  1790).  Lesne,  Petit's  pupil  and  «'<li- 
tor,  referring  to  Cheselden's  publication  of  1749,  declares  that  Petit  had  publicly  taught  this 
method  "  more  than  thirty  years  before."  (Traite  des  Maladies  Chirurgicales,  etc.  [Petit],  Dis- 
cours  Preliminaire,  t.  i.  p.  lxv.) 

1  Bartolomsei   Maggii    de  vulnernm   sclopetorum  et  bombardarum   curatione  tractatus.      De 
Chirurgia  Scriptores,  etc.  [ed.  Conrad  Gesner],  fol.  267  et  seq.     Tiguri,  1555. 

2  Memoires  de  l'Academie  Royale  de  Chirurgie,  t.  ii.  pp.  185,  248  ;  t.  iv.  p.  159.      Paris,  1819. 

3  Recherches  critiques  sur  la  chirurgie,  p.  135. 

4  Practical  Observations  in  Surgery,  page  318.     Philadelphia,  1805. 

5  Practical  Observations  on  Amputation,  etc.,  page  15.     Second  edition.     London,  1782. 

6  System  of  Surgery,  seventh  edition,  vol.  vii.  page  2(55.     Edinburgh,  1801. 


558  AMPUTATIONS. 

provement  by  which  a  sufficient  covering  was  secured  for  the  stump  by  dis- 
secting up  the  skin  and  fascia  so  as  to  form  a  cuff,  which  was  afterwards 
brought  down  over  the  muscles  and  bone.  Bromfeild  came  very  near  suggest- 
ing this  improvement,  but,  as  Alanson  points  out,  just  missed  it.1  Alanson, 
who  like  Desault,2  in  France,  preferred  a  straight  knife  to  the  heavy  knives 
with  concave  edges,  which  were  commonly  employed  in  amputations,  made 
his  deep  incision  by  applying  the  knife  obliquely,  and  cutting  the  muscles 
into  the  form  of  a  hollow  cone ;  but  other  operators  did  not  succeed  in  fol- 
lowing his  directions,  finding  that  a  knife  thus  used  was  more  apt  to  make  a 
spiral  than  a  circular  incision,  and  his  peculiar  mode  of  operating  is  now 
looked  upon  merely  as  a  matter  of  historical  interest.  "When  the  limb  was 
a  large  one,  Desault  divided  the  muscles  in  two  layers ;  he  also  divided  the 
skin  by  two  semicircular  incisions,  instead  of  making  one  complete  circle, 
but,  like  Petit,  he  divided  the  bone  on  a  level  with  the  highest  section  of  the 
muscles.3  The  operation  of  Bell  and  Hey — that  "  with  a  triple  incision,"  as 
the  latter  called  it,4  the  skin  and  fascia  being  first  divided  and  dissected  up 
for  a  sufficient  distance,  then  the  muscles  cut  and  separated  from  the  bone, 
and  this  finally  sawn  through  at  a  still  higher  point — constitutes  in  all  essen- 
tial particulars  the  circular  operation  of  the  present  day. 

The  first  flap  operation  appears  to  have  been  suggested  by  Lowdham,  of 
Exeter,  as  described  by  Young,  of  Plymouth,  in  his  "  Currus  triumphalis  e 
terebintho,"  published  in  1679.5  Velpeau,6  however,  declares  that  the  opera- 
tion was  clearly  described  by  both  Leonidas  and  Heliodorus  at  a  much  earlier 
period.  Velpeau's  statement  seems  to  me  to  be  hardly  justified:  the  opinions 
of  Leonidas,  or  Leonides,7  are  known  only  through  the  writings  of  .^Etius  and 
Paulus  vEgineta,  the  latter  surgeon  giving  his  views  upon  amputation,  as 
already  referred  to  ;8  while  the  only  passage  in  the  extant  fragments  of  Helio- 
dorus,9 which  can,  with  any  degree  of  fairness,  be  considered  a  description 
of  the  flap  operation,  is  his  direction  that  in  removing  superfluous  fingers  a 
circular  incision  should  be  first  made,  and  then  straight  cuts  on  either  side 
from  this,  when  two  bodies  or  parts  were  to  be  raised  up  (Jta  avaari^urai  6vu> 
o^fxata)  ;10  but  in  his  general  remarks  on  amputation  he  certainly  says  nothing 
which  can  be  reasonably  construed  into  a  description  of  the  flap  method.11 
Lowdham's  and  Young's  operation  was  applied  to  the  leg,  and  consisted  in 
cutting  from  without  inwards  a  long  flap  of  skin  and  fascia  from  over  the  mus- 
cles of  the  caxf.  Verduin,12  of  Amsterdam,  in  1696,  and  Sabourin,  of  Geneva, 
in  1702,13  introduced  the  plan  of  forming  a  musculo-cutaneous  flap  from  the  calf 
of  the  leg,  by  transfixion,  and  attempted  to  control  the  bleeding  by  pressing 
this  firmly  against  the  end  of  the  stump;  Verduin 's  flap  was  adopted  by 
Garengeot,14  who,  however,  ligated  the  bleeding  vessels,  and  thus  perfected 
the  ordinary  flap  operation  of  the  leg  as  it  is  still  often  practised  at  the  pre- 
sent day.     O'Halloran,15  an  Irish  surgeon,  likewise  employed  this  mode  of 

1  f  hirurgical  Observations  and  Cases.    By  William  Bromfeild,  etc.,  vol.  i.  page  151.    London, 
1773. 

2  (Euvres  chirursicah's,  seconde  partie,  p.  491.     Paris,  1798. 

»  Op.  cit.,  pp.  4-0,  492.  *  Op.  cit.,  p.  317. 

6  La  Faye,  Histoire  de  F  amputation  a  lambeau,  etc.,  Mem.  de  l'Acad.  Royale  de  Chirurgie,  t. 
ii.  p.  169.     Paris,  1819. 
8  Nouveaux  elements  de  meMeoitie  opfiratoire,  t.  ii.  p.  300. 
»  Haller,  Bibliotheoa  ehirurgica,  t.  i.  p.  79.        8  Vide  supra,  page  553.         9  Op.  cit.,  p.  158. 

10  This  was  rather  an  anticipation  of  Kavaton's  double-flap  method  than  of  Lowdham's  opera- 
tion. 

11  Op.  cit.,  p.  150.     Vide  supra,  page  553. 

12  Mangetus,  H i  1  > M <» 1 1 1 *'<••■  t  scriptoruni  medicorum,  lib.  xx.  t.  ii.,pars  ii.,  p.  493,  and  Garengeot, 
Tr.-iiti'  des  operations,  t.  iii.  p.  393. 

"  La  Fay-',  loo.  cit.,  p.  17<>. 

14  Mem.  de  l'Acad.  Royale  de  Chirurgie,  t.  ii.  p.  180. 

15  The  Medical  Museum,  vol.  iii.  p.  G5.     London,  1704. 


CONDITIONS   CALLING   FOR   AMPUTATION.  559 

amputation,  but  did  not  close  the  stump  until  tlie  flap  was  already  covered 
with  granulations.  The  earliest  double-Jiap  amputation  (if  we  except  Helio- 
dorus's  operation  on  the  fingers),  appears  to  have  been  practised  by  Kavaton,1 
a  French  surgeon,  about  the  year  1739.  He  applied  this  method  of  operating 
to  the  thigh,  making  first  a  circular  incision  down  to  the  bone,  and  supple- 
menting this  by  longitudinal  incisions  in  front  and  behind,  making  thus  two 
square,  muscular,  lateral  flaps,  at  the  point  of  junction  of  which  the  bone 
was  then  divided.  Vermale2  modified  and  improved  this  procedure  by  mak- 
ing the  flaps  of  a  rounded  or  somewhat  oval  shape,  and  by  forming  them  by 
transfixing  the  limb  with  a  long  knife  and  cutting  from  within  outwards. 
La  Faye's  suggestion3  to  use  a  knife  curved  on  the  flat  that  it  might  better  slip 
around  the  bone,  appears  more  ingenious  than  practically  valuable. 

The  flap  operation,  in  one  or  other  of  its  forms,  was  soon  adopted  by  other 
surgeons,  and  with  various  modifications  was  finally  brought  into  ordinary 
use  through  the  example  mainly  of  Listen  and  Guthrie  in  England,  of  Du- 
puytren,  Roux,  and  Larrey  in  France,  and  of  Klein  and  Langenbeck  in  Ger- 
many. All  the  various  forms  of  amputation  which  have  been  since  employed, 
may  be  regarded  as  varieties  of  these  two  principal  methods,  the  flap  and  the 
circular. 


Conditions  calling  for  Amputation. 

It  is  not  intended,  of  course,  in  the  following  paragraphs,  to  enumerate 
and  describe  all  the  various  contingencies  which  may  determine  a  surgeon  to 
resort  to  amputation.  There  is  hardly  any  form  of  injury,  or  variety  of  dis- 
ease, capable  of  affecting  a  limb,  which  may  not,  under  particular  circum- 
stances, whether  as  regards  the  constitution  and  hygienic  condition  of  the 
patient,  or  the  individual  and  peculiar  features  of  the  special  lesion,  necessi- 
tate a  resort  to  this  operation.  All  that  is  meant  to  be  done  here  is  to  bring 
together,  in  a  compendious  way,  brief  references  to  the  more  important  con- 
ditions which,  as  a  rule,  render  imperative  the  removal  of  a  limb,  so  that  the 
reader  may  obtain,  as  it  were,  a  bird's-eye  view  of  the  subject,  and  may  thus 
be  enabled  to  realize  to  what  a  vast  diversity  of  cases  the  "humane  operation" 
of  amputation  is  applicable. 

Avulsion  of  a  Limb. — In  the  first  place,  it  can  be  readily  understood  that 
when  any  considerable  part  of  an  extremity  has  been  torn  oft'  and  entirely 
separated  from  the  body,  there  is  commonly  no  alternative  to  immediate 
amputation.  The  operation  may  indeed  be  said  to  have  been  already  effected 
by  the  force  which  caused  the  injury,  and  the  surgeon's  part  is  merely  to  trim 
oft'  the  hanging  shreds  of  tisstte,  and  put  the  wound  in  such  a  condition  that 
it  may  heal  more  readily,  and  that  the  resulting  stump  may  be  of  better  shape 
and  more  useful  than  if  the  process  of  repair  had  been  entirely  abandoned  to 
the  efforts  of  nature.  Even  though  the  part  be  not  altogether  separated,  if 
it  be  hanging  merely  by  integument  and  fascia,  the  great  vessels  as  well  as 
the  bone  and  most  of  the  muscles  having  been  divided,  the  surgeon's  duty  is 
to  amputate.  A  few  authentic  cases  are  no  doubt  on  record  in  which  small 
portions  of  the  body,  tips  of  the  fingers,  or  bits  of  the  'nose  or  ears,  have 
been  re-applied  after  complete  separation,  and  have  become  reunited  :  but 
even  these  restorations  are,  in  this  climate  at  least,  so  rare,  that  their  possi- 
bility may  be  practically  disregarded  ;  while  in  respect  to  the  cases  which  we 

1  La  Faye,  loc.  cit.  p.  174.     Le  Dran,  op.  cit.  p.  5fi4. 

2  La  Faye,  loc.  cit.  p.  175.     Le  Dran,  op.  cit.  p.  567.  8  Loc.  cit. 


560  AMPUTATIONS. 

occasionally  find  described  in  journals,  of  large  portions,  hands  or  arms,  being 
thus  re-connected  with  the  body,  I  must  confess  to  entire  incredulity. 

Compound  Fractures  and  Luxations  very  frequently  necessitate  removal 
of  the  injured  part.  Most  of  the  primary  amputations  performed  in  our 
large  city  hospitals  are  in  cases  of  compound  fracture,  and  though  limbs  are 
undoubtedly  saved  now  which  in  past  times  would  have  been  sacrificed,  yet 
with  the  increase  of  railway  travelling  and  the  more  general  employment  of 
heavy  machinery  in  manufactures,  the  number  of  accidents  of  this  nature 
lias  been  so  augmented  that  amputation  for  injury  becomes,  year  by  year,  a 
more  frequent  operation  in  hospital  practice.  The  propriety  of  amputation 
in  compound  fractures  maybe  determined  by  various  considerations: — 

(1)  Great  comminution  of  the  bones  may  of  itself  be  a  cause  for  amputation. 
In  the  upper  extremity,  conservative  measures  may  often  be  successful,  loose 
or  partially  detached  fragments  being  removed,  and  projecting  ends  of  bone 
sawn  off  if  necessary  to  effect  reduction ;  but  in  fractures  of  the  lower 
extremity,  if  the  fragments  which  require  removal  involve  the  whole  thick- 
ness of  the  femur  or  tibia,  the  resulting  limb,  should  recovery  follow,  would 
in  all  probability  be  rather  an  encumbrance  than  a  benefit,  and  under  such 
circumstances  amputation  should  ordinarily  be  resorted  to. 

(2)  Laceration  of  a  large  artery,  in  connection  with  compound  fracture, 
usually  calls  for  amputation.  Here,  again,  a  distinction  may  be  made  between 
injuries  of  the  upper  and  those  of  the  lower  extremity ;  in  the  case  of  the 
former,  an  attempt  may  sometimes  properly  be  made  to  save  the  limb  by 
tying  the  vessel  in  the  wound,  or  even  by  securing  the  main  trunk  above, 
but  in  the  case  of  the  lower  extremity,  unless  the  bleeding  artery  can  be 
readily  found  and  ligated  in  the  wound  itself,  amputation  will  be  found  the 
safest  mode  of  procedure.  So,  too,  in  case  of  secondary  hemorrhage  occur- 
ring as  a  complication  of  compound  fracture  in  the  lower  extremity,  amputa- 
tion will  commonly  be  necessary. 

(3)  Great  contusion  and  laceration  of  the  muscles,  even  if  the  great  vessels  be 
uninjured,  may  be  considered  to  indicate  amputation  in  many  cases  of  com- 
pound fracture.  A  limb  which  has  been  crushed  by  the  wheels  of  a  railway 
train,  almost  invariably  requires  amputation,  the  muscles  and  other  deep- 
seated  tissues  being  torn,  and,  as  it  were,  pulpefied,  while  the  skin  may  be 
comparatively  uninjured.  In  such  a  case  the  operation  should,  as  a  rule,  be 
performed  at  a  higher  level  than  that  at  which  the  skin  is  found  to  be  sepa- 
rated from  the  subjacent  tissues,  as  otherwise  sloughing  of  the  flaps  will  be 
apt  to  follow,  and  a  second  amputation  may,  perhaps,  be  required. 

(4)  Compound  fracture  into  the  knee-joint  may  be  considered  a  cause  for  am- 
putation, and  the  same  operation  will  often  be  required  in  cases  of  compound 
fracture  involving  the  ankle.  In  similar  injuries  involving  the  other  joints 
of  the  body,  and,  under  favorable  circumstances,  in  the  instance  of  the  ankle, 
excision  should  be  the  surgeon's  first  thought,  and  may  often  be  properly 
substituted  for  amputation. 

Compound  dislocations  of  large  joints  are  among  the  most  serious  injuries 
to  which  the  human  frame  is  liable,  and;  in  my  judgment,  almost  always 
require  operative  interference;  in  the  case  of  the  hip  or  ankle,  or  of  the  arti- 
culations of  the  upper  extremity,  excision  may  be  preferred,  but  in  the  case 
of  the  knee  amputation  is  the  safer  remedy,  and  may,  indeed,  be  said  to  be 
imperatively  demanded. 

Lacerated  and  Contused  Wounds,  even  when  unattended  byunjuries  of  the 
bones  or  joints,  may  require  amputation.    Operatives  in  mills  not  unfrcquently 


CONDITIONS   CALLING    FOR   AMPUTATION.  561 

have  their  arms  caught  in  portions  of  the  machinery,  and  drawn  between 
rollers  revolving  in  opposite  directions;  in  many  of  these  eases,  provided 
that  there  be  no  fracture,  expectant  measures  may  undoubtedly  suffice,  and  I 
have  frequently  saved  limbs  thus  injured  by  the  use  of  irrigation,  with  cool 
or  tepid  water,  according  to  the  season  of  the  year.  In  some  instances,  how- 
ever, the  destruction  of  the  integument  and  muscles  is  so  extensive  that  the 
inevitable  sloughing  would  render  the  limb,  even  if  it  should  be  preserved,  a 
mere  useless  appendage,  and,  under  such  circumstances,  amputation  should  be 
resorted  to,  as  not  only  greatly  shortening  the  duration  of  the  treatment,  but 
as  delivering  the  patient  from  many  of  the  secondary  risks  of  wounds  to 
which  he  would  otherwise  be  liable.  The  same  may  be  said  in  regard  to  cer- 
tain injuries  caused  by  railway  trains  or  heavily  loaded  wagons;  a  foot  and 
ankle  from  the  greater  part  of  which  all  the  soft  tissues  have  been  stripped, 
or  bruised  into  an  indistinguishable  pulp,  can  never  be  anything  but  a  source 
of  suffering  and  discomfort  to  its  possessor,  and  under  most  circumstances 
should  be  removed  as  promptly  as  possible.  In  this  category,  too,  may  be 
placed  the  frightful  lacerations  sometimes  caused  by  the  teeth  and  claws  of 
wild  animals  ;  these  are,  of  course,  more  common  in  countries  of  which  such 
animals  are  natives,  than  in  our  own ;  but  they  are  occasionally  met  with 
among  the  attendants  or  visitors  at  menageries,  and  I  have  myself  had  occa- 
sion to  see  wounds  inflicted  by  a  Polar  bear,  a  lion,  and  a  Royal  Bengal 
tiger. 

The  last-mentioned  case  occurred  during  my  student  days,  and  the  victim,  a  youn^ 
woman,  was  admitted  to  the  Pennsylvania  Hospital,  where  she  came  under  the  care  of 
the  late  Dr.  Edward  Peace.  The  injury,  inflicted  by  a  blow  from  the  claws  of  the 
animal,  was  a  very  severe  laceration  of  the  arm,  involving  the  brachial  artery.  Primary 
amputation  at  the  shoulder-joint  was  resorted  to,  and  the  patient  made  an  excellent 
recovery. 

The  case  of  bear-wound  occurred  in  a  man  who  was,  a  few  years  since,  under  my 
care  in  the  University  Hospital ;  there  was  a  tolerably  severe  and  painful  laceration  of 
the  arm  and  shoulder,  but  not  such  as  to  require  operative  interference,  and  the  wound 
healed  readily  under  simple  dressings. 

The  case  of  lion-wound  was  the  only  one  of  the  three  which  terminated  fatally. 
This  occurred  in  a  man  aged  25,  a  professional  "  lion-tamer,"  who,  in  the  course  of  his 
daily  rehearsal,  placed  his  head  in  the  lion's  mouth,  when  the  animal  unexpectedly 
closed  his  jaws.  The  by-standers  rushed  to  the  rescue,  and  with  clubs  and  iron  bars 
forced  the  wild  beast  to  relax  his  hold,  but,  unfortunately,  his  victim  did  not  make  his 
escape  with  sufficient  promptness,  and  the  lion  again  attacked  him,  throwing  him  down, 
and  this  time  seizing  him  by  the  fleshy  part  of  the  thigh.  I  did  not  see  the  patient 
until  the  next  day,  when  he  was  not  in  a  condition  to  admit  of  any  operation.  The 
injured  thigh  was  already  the  seat  of  traumatic  gangrene,  which  had  set  in  within 
eighteen  hours  after  the  reception  of  the  injury ;  the  limb  was  enormously  swollen, 
emphysematous  and  crackling  from  the  gaseous  products  of  decomposition,  and  discharg- 
ing from  its  numerous  wounds,  some  of  which  were  two  or  more  inches  in  length,  a 
bloody,  sanious,  and  very  offensive  fluid.  The  pulse  was  running  at  the  rate  of  172 
beats  in  the  minute,  and  it  was  quite  evident  that  a  fatal  issue  was  impending. 
Death  occurred  shortly  after  the  gangrene  reached  the  trunk,  the  whole  duration  of  the 
case  having  been  just  forty-eight  hours.  Had  amputation  at  the  hip-joint  been  per- 
formed before  or  immediately  upon  the  occurrence  of  gangrene,  there  might  have  been 
some  slight  hope  of  the  patient's  surviving.  This  case  was  under  my  care  at  the  Epis- 
copal Hospital  in  April,  1872. 

Gunshot  Injuries  often  call  for  amputation.     The  increased  power  of  de- 
struction possessed  by   modern   implements  of  warfare,  to  a  great   extent 
counterbalances  the  improvements  which  have  been  made  in  the  treatment 
of  wounds  ;  so  that  though,  by  the  introduction  of  the  operations  of  exeision 
vol.  i. — 36 


562  AMPUTATIONS. 

and  resection  into  military  surgery,  many  limbs  can  now  be  preserved  which 
would  formerly  have  been  condemned  to  removal,  yet  the  proportion  of  cases 
in  which  the  army  surgeon  is  compelled  to  amputate,  is  probably  almost  if 
not  quite  as  large  as  when,  though  surgery  was  less  efficient,  the  injuries  with 
which  it  had  to  deal  were  less  severe.  The  conical  ball,  propelled  by  the 
modern  rifled  firearm,  splits  and  shatters  the  bone  which  it  strikes  so  severely, 
as  very  often  to  defeat  any  hope  of  doing  good  by  expectant  treatment ;  and 
when  simple  extraction  of  fragments  is  not  sufficient,  and  the  surgeon  has  to 
choose  between  amputation  and  resection,  the  former  will  frequently  be  found 
the  more  eligible  operation. 

Various  Lesions  of  Arteries  require  amputation.  Simple  wounds  of 
arteries  are,  of  course,  usually  amenable  to  milder  measures,  and  subcutaneous 
ruptures  or  lacerations  of  the  great  vessels  may  often  be  successfully  treated 
by  laying  open  the  part,  after  controlling  the  circulation  with  a  tourniquet 
or  Esmarch's  tube,  or  even  with  digital  compression,  and  by  securing  the 
artery  as  if  it  had  bled  in  an  open  wound.  In  certain  situations,  however,  as 
when  the  popliteal  artery  is  the  seat  of  rupture,  amputation  will  commonly 
be  needed.  Again,  traumatic  aneurisms,  or  spontaneous  aneurisms  which 
have  become  diffuse,  may  require  amputation  ;  this  rule  particularly  applies 
to  aneurisms  of  the  popliteal  artery,  and  of  the  deep  arteries  of  the  leg,  and 
to  traumatic  aneurisms  in  the  axilla.  Amputation  has  also  been  successfully 
practised  as  a  modified  distal  ligation  in  cases  of  subclavian  aneurism.  Finally, 
amputation  may  be  demanded  in  cases  of  secondary  hemorrhage,  whether  from 
a  wounded  artery  or  from  one  previously  ligated  in  its  continuity.  .The  reason 
that  amputation  is  often  more  successful  under  such  circumstances  than  any 
other  measure,  can  be  readily  understood  when  it  is  remembered  that  secon- 
dary bleeding  almost  invariably  comes  from  the  distal  end  of  a  vessel  (where 
the  repair  is  less  perfectly  effected  than  at  the  proximal  end),  and  that  only 
by  amputation  can  the  vis  a  fronte  which  induces  the  supply  of  blood  to  the 
distal  end  be  got  rid  of. 

Heat  and  Cold. — Amputation  is  not  unfrequently  rendered  necessary  by 
the  destructive  influence  of  heat  or  cold.  In  cases  of  frost-bite,  the  dead  parts, 
if  limited  in  extent,  should  be  allowed  to  drop  off  spontaneously ;  if  a  whole 
hand  or  foot  be  involved,  the  sphacelated  mass  may  be  removed  by  an  inci- 
sion through  the  dead  tissues,  and  then,  when  the  lines  of  demarcation  and 
separation  have  been  fully  established,  a  formal  operation  may  be  practised. 
So,  too,  in  cases  of  burns  or  scalds,  no  operation  should  as  a  rule  be  attempted 
until  after  the  sloughs  have  all  become  detached,  when,  if  it  be  evident  that 
a  cure  is  not  to  be  expected  from  nature's  unaided  efforts,  amputation  may 
be  resorted  to  with  the  best  prospects  of  a  favorable  result.  The  same  opera- 
tion may  also  be  called  for  at  a  later  period  in  cases  of  great  deformity  re- 
sulting from  cicatricial  contraction,  or  when,  as  sometimes  happens,  old  cica- 
trices become  the  seat  of  malignant  growths. 

Mortification  from  whatever  cause,  when  the  death  of  the  part  goes  be- 
yond the  formation  of  a  mere  superficial  slough,  usually  demands  amputation. 
The  ordinary  ride,  and  one  that  under  most  circumstances  should  be  strictly 
adhered  to,  is  that  no  amputation  should  be  undertaken  until  after  the  com- 
plete establishment  of  the  line  of  separation;  the  reason  is  obvious — if  the 
surgeon  cut  through  parts  the  vitality  of  which  is,  as  it  were,  hanging  in  the 
balance,  the  additional  injury  inflicted  by  the  knife  may  of  itself  be  sufficient 
to  turn  the  scale,  and  an  amputation  under  these  circumstances  is  apt  to  be 
followed  by  a  renewal  of  the  gangrenous  process.     Hence  when  death  of  a 


CONDITIONS    CALLING    FOR    AMPUTATION.  563 

part  results  simply  from  the  intensity  of  the  inflammatory  process,  as  in  the 
cases  of  frost-bite  and  burn,  already  referred  to,  no  operation  should  be  done 
while  the  mortification  is  still  extending,  but  the  surgeon  should  await 
nature's  indication  that  the  limit  of  the  destructive  process  has  been  reached, 
and  may  then  amputate  at  any  point  above  the  line  of  separation  which  may 
be  found  convenient.  There  are,  however,  exceptions  to  this  ordinarily  well- 
founded  rule.  Thus  in  the  purely  local  forms  of  gangrene  which  result  from 
direct  injury,  as  in  severe  cases  of  compound  fracture  in  which  for  some 
reason  primary  amputation  has  not  been  practised,  the  limb  should  be  re- 
moved as  soon  as  the  signs  of  mortification  are  unequivocally  manifested ; 
delay  under  these  circumstances  would  commonly  result  in  the  patient's 
death  before  time  had  been  given  for  the  formation  of  a  line  of  separation. 
Again,  in  that  frightful  form  of  mortification  which  is  variously  known  as 
the  true  "traumatic  or  spreading  gangrene,"  "bronzed  erysipelas,"  "  gangre- 
nous emphysema,"  etc.,  the  only  hope,  and  that,  it  must  be  confessed,  but  a 
slight  one,  consists  in  immediate  amputation  at  a  point  sufficiently  removed 
from  the  seat  of  disease  to  render  unlikely  a  recurrence  of  gangrene  in  the 
stump;  this  was  the  form  of  gangrene  which  occurred  in  the  case  of  fatal  in- 
jury by  a  lion  which  I  have  already  referred  to ;  it  is  most  common  in  con- 
nection with  bad  compound  fractures  and  severe  lacerated  wounds,  though  it 
may  follow  comparatively  slight  injuries,  and  is  particularly  apt  to  occur  in 
persons  who  are  suffering  from  previously  existing  visceral  disease,  and  espe- 
cially from  organic  affections  of  the  kidney. 

There  is  another  form  of  gangrene  which  may  require  immediate  ampu- 
tation, and  that  is  where  death  of  a  part  results  from  an  arterial  lesion  at  a 
distant  point,  as  where  mortification  of  the  foot  depends  upon  a  gunshot 
wound  of  the  femoral  artery.  The  gangrene  in  these  cases  first  displays 
itself  through  a  change  in  the  coloration  of  the  affected  part,  which  is  in  the 
beginning  pale  and  tallow-like,  and  afterwards  mottled  and  streaked,  while 
numbness  is  succeeded  by  complete  insensibility.  Guthrie's  advice  as  to  the 
course  to  be  pursued  under  such  circumstances,  appears  to  be  judicious;  this 
is  that  while  the  gangrene  remains  limited  to  the  toes  or  foot,  the  surgeon 
should  delay,  in  hope  that  it  will  not  extend  further;  but  that  as  soon  as  the 
disease  shows  a  tendency  to  spread  above  the  ankle,  amputation  should  be 
performed  at  that  point  at  which  experience  has  shown  that  the  morbid  pro- 
cess is  likely  to  be  arrested,  that  is,  a  short  distance  below  the  knee.  If  the 
upper  extremity  should  be  similarly  affected,  the  point  at  which  the  arm 
should  be  removed  would  be  the  shoulder-joint. 

Dry  Gangrene,  affecting  the  extremities  of  old  persons,  seldom  admits  of 
active  treatment,  the  disease  almost  invariably  recurring  in  the  stump  when 
an  amputation  is  attempted.  To  avoid  this  risk,  it  has  been  recommended 
by  James,  of  Exeter,  and  other  surgeons,  that,  for  gangrene  affecting  the  toes, 
the  operation  should  be  done  in  the  upper  part  of  the  thigh,  where  the 
tissues  would  presumably  be  more  healthy  than  at  a  lower  point ;  but  it  is 
obvious  that  the  constitutional  state  of  the  patient,  in  most  cases  of  senile 
gangrene,  would  render  such  a  mode  of  treatment  hazardous  in  the  extreme. 
Greater  success  attends  amputation  for  those  forms  of  dry  gangrene  which  are 
occasionally  met  with  in  young  persons,  as  the  result  for  instance  of  em- 
bolism ;  but  even  in  such  cases,  the  surgeon  should  hesitate  about  interfering 
until  the  formation  of  a  line  of  separation  shows  that  nature  is  making  an 
effort  to  throw  off  the  portion  of  which  the  vitality  has  been  lost.  Amputa- 
tion may  also  be  required  in  cases  of  Hospital  Gangrene,  or  sloughing  pha- 
gedena, either  after  the  morbid  process  has  been  arrested,  on  account  of  the 
great  loss  of  substance,  or  even  during  its  continuance,  should  profuse  bleed- 
ing occur  from  the  opening  of  a  large  artery.     In  the  latter  case,  care  should 


564  AMPUTATIONS. 

be  taken  to  amputate  through  healthy  tissues,  and  every  precaution  should 
be  observed  to  avoid  the  risk  of  inoculating  the  wound  of  operation  with  the 
discharges  from  the  original  seat  of  disease. 

Various  Diseases  of  the  Bones  and  Joints  may  necessitate  removal  of  the 
affected  limb.  If  either  alone  be  diseased,  less  sweeping  measures  may  suffice, 
excision  taking  the  place  of  amputation  in  favorable  cases  of  joint-disease, 
and  the  extraction  of  sequestra,  Sedillot's  operation  of  evidement  (gouging), 
or,  in  some  instances,  complete  sub-periosteal  resection,  usually  proving 
satisfactory  when  the  bones  only  are  affected  without  implication  of  the 
neighboring  articulations.  Much,  however,  as  I  admire  the  practice  of 
"  conservative  surgery,"  and  striving  as  I  invariably  do  to  substitute  excision 
and  the  other  operations  which  have  been  referred  to,  for  amputation,  in  all 
suitable  cases,  I  cannot  doubt  that  there  will  always  be  a  considerable  resi- 
duum of  bone  and  joint-affections,  in  wThich  the  "humane  operation"  will 
offer  the  only  chance  of  recovery. 

Morbid  Growths  not  unfrequently  become  causes  for  amputation.  It  may 
even  happen  that  a  non-malignant  tumor,  by  its  size  and  weight,  by  its  rela- 
tions to  the  great  vessels  and  nerves  of  an  extremity,  or,  if  suppuration  and 
ulceration  have  occurred  in  it,  by  the  exhaustion  caused  by  profuse  dis- 
charge, may  render  removal  of  the  affected  limb  a  more  promising  operation 
than  an  attempt  to  separate  the  growth  from  the  surrounding  tissues ;  while 
in  the  case  of  malignant  tumors  of  the  extremities,  and  particularly  those 
involving  the  bones,  including  (as  clinically  malignant)  the  sarcomata,  car- 
tilaginous growths,  etc.,  amputation  is  commonly  the  sole  remedy.  It  is  true 
that,  in  some  few  instances,  excision  of  the  affected  portion  of  bone  has  been 
advantageously  resorted  to,  as  in  the  examples  recorded  by  Lucas  and  Morris, 
in  which  myeloid  growths  of  the  forearm  were  thus  successfully  dealt  with ; 
but  in  the  majority  of  cases,  amputation  will  be  found  the  safer  measure,  and 
under  these  circumstances  may  usually  be  resorted  to  with  every  prospect  of 
a  favorable  termination. 

Tetanus  has  been  looked  upon  as  an  affection  calling  for  amputation,  and 
a  cure  has  occasionally  followed  the  operation.  Laurent  has  collected  seven- 
teen cases  of  minor,  and  twenty-four  of  major  amputation  for  tetanus,  with 
eleven  recoveries  in  either  category,  or,  taking  both  together,  a  proportion  of 
successes  of  nearly  fifty-four  per  cent.  In  most  instances,  however,  the  cases 
appear  to  have  been  examples  of  subacute  or  chronic  tetanus,  in  which  a  good 
result  may  often  be  obtained  by  internal  treatment  alone,  and  on  the  other 
hand  the  milder  operations  of  nerve-stretching  and  neurotomy  have  given  at 
least  as  good  results  as  amputation ;  we  may  probably  say,  therefore,  in  view 
of  all  the  evidence  which  has  been  produced  in  respect  to  the  matter,  that 
while,  if  the  operation  appear  to  be  otherwise  indicated,  the  onset  of  tetanus 
may  be  considered  an  additional  reason  for  resorting  to  amputation,  this 
should  not  be  indiscriminately  employed  in  all  instances  of  tetanus  originat- 
ing in  wounds  of  the  extremities,  without  regard  to  the  other  circumstances 
of  the  particular  case. 

I  cannot  look  upon  amputation  as  a  justifiable  procedure  in  cases  of  hydro- 
phobia, nor,  unless  under  very  exceptional  circumstances,  in  those  of  poisoned 
ivounds  from  the  bites  of  serpents,  etc. 

Deformities. — Finally, amputation  maybe  sometimes  practised  in  cases  of 

congenital  malformation,  as  in  some  instances  of  neglected  club-foot^or  in 

of  limbs  deformed  by  accident  or  disease,  the  result  of  vicious  cicatri- 


INSTRUMENTS    REQUIRED    FOR    AMPUTATION.  565 

cial  contraction,  union  of  fractures  in  bad  positions,  faulty  anchylosis,  etc. 
Amputation  in  cases  such  as  these,  must  be  considered  an  operation  of  election, 
or  of  complaisance,  and  should  not  be  resorted  to,  therefore,  except  under  cir- 
cumstances as  regards  the  age  and  general  condition  of  the  patient  which 
would  render  an  unfavorable  termination  exceedingly  improbable,  and  even 
then  not  without  a  full  appreciation  of  the  risks  of  the  operation  on  the  part 
of  all  concerned. 


Instruments  required  for  Amputation. 

Before  undertaking  an  amputation,  as,  indeed,  before  attempting  any  ope- 
ration, the  surgeon  should  run  over  in  his  mind  all  the  various  instruments 
and  appliances  that  may  possibly  be  required  by  the  several  contingencies 
which  may  arise.  He  should  see  that  all  the  necessary  implements  are  at 
hand,  and  in  working  order;  there  can  be  nothing  more  awkward  than  for 
the  surgeon,  after  making  his  flaps,  to  discover  that  the  saw  has  been  forgot- 
ten, or,  when  the  limb  has  been  removed,  that  he  is  likely  to  run  short  of 
ligatures,  or  that  the  needle  with  which  he  proposes  to  sew  up  the  wound, 
has  no  point,  or  a  broken  eye.  jNTor  is  the  inconvenience  to  the  operator  the 
worst  result  of  this  kind  of  improvidence,  for  the  delay  caused  in  procuring 
the  missing  articles  may  prove  very  prejudicial  to  the  patient. 

The  instruments  needed  for  amputations  are  a  tourniquet,  or  other  suitable 
means  for  controlling  the  circulation  during  the  various  steps  of  the  opera- 
tion, knives  of  various  forms  and  dimensions,  saws  of  different  kinds,  bone- 
nippers  or  cutting  pliers,  a  pair  of  strong  forceps  for  holding  bone,  artery 
forceps  and  tenacula,  spring-clips  and  serre-tines,  ligatures,  retractors,  sutures 
and  suture  needles,  common  dissecting  forceps,  and  scissors.  Besides  these, 
the  necessary  means  of  dressing  the  stump  should  be  provided ;  laudanum, 
olive  oil,  or  whatever  substance  the  surgeon  intends  to  employ  as  a  dressing, 
adhesive  plaster,  sheet  lint  or  old  linen,  oiled  silk  or  waxed  paper,  charpie  or 
oakum,  bandages,  pins,  etc. 

Tourniquet. — As  already  mentioned,  the  first  attempt  to  control  bleeding 
during  an  amputation  appears  to  have  been  made  by  Archigenes,  who  some- 
times placed  a  fillet  around  the  whole  limb,  and  sometimes  tied  or  sewed  up 
the  vessels  at  a  point  above  that  at  which  it  was  intended  to  amputate.  The 
fillet  answered  its  purpose  very  imperfectly,  and  the  invention  of  Morel,  by 
which  sticks  were  thrust  under  the  band,  and  twisted  around  so  as  to  com- 
press the  limb  tightly,  wTas  unquestionably  an  improvement.  Morel's  tour- 
niquet as  further  modified  by  Ledran  is  still  employed  occasionally  with 
advantage  in  cases  of  emergency,  under  the  name  of  the  "garrot"  or  "  Span- 
ish windlass."  The  best  tourniquet  for  ordinary  use  is  in  all  important  pi  nuts 
the  same  as  that  introduced  in  the  early  part  of  the  last  century  by  Petit, 
and  consists  of  two  metal  plates,  the  distance  between  which  can  be  regulated 
by  means  of  a  screw,  and  which  are  connected  by  a  strong  silk  or  linen  strap, 
which  is  meant  to  pass  around  the  limb,  and  which  is  provided  with  a  buckle 
to  prevent  its  slipping  (Fig.  105).  The  plan  which  I  have  now  for  a  good 
many  years  adopted  m  applying  the  tourniquet  is  as  follows:  The  surgeon, 
taking  an  ordinary  three-inch  or  four-inch  roller  bandage,  makes,  by  unrol- 
ling and  again  folding  one  end  of  it,  a  somewhat  flat  compress,  which  is  placed 
immediately  over  the  main  artery  of  the  limb  at  a  point  at  which  its  pulsations 
can  be  distinctly  recognized.  This  compress  is  fixed  by  a  few  circular  turns 
of  the  bandage,  and  the  rest  of  the  roller  is  then  laid  as  a  second  compress 
somewhat  obliquely  across  the  vessel,  so  as  to  force  inwards  the  first  compress, 


566 


AMPUTATIONS. 


Fig.  105. 


and  keep  up  the  tension  even  if  the  tourniquet-plate  should  he  slightly 
displaced  to  one  or  the  other  side.  The  tourniquet  is  next  applied,  with  its 
plates  closely  approximated,  and  placed  immediately  over  the  compresses, 
so  as  to  exercise  pressure  in  the  line  from  the  compresses  through  the  vessel, 

to  the  subjacent  hone.  The  strap 
is  then  drawn  quite  tight,  and  se- 
cured by  the  buckle,  when  a  few 
turns  of  the  screw  will  be  found  to 
completely  control  the  circulation. 
It  is  desirable  that  the  plates  of  the 
instrument  should  not  be  separated 
by  more  than  half  the  length  of  the 
screw,  as  if  separated  by  its  full  ex- 
tent, the  instrument  becomes,  as  it 
were,  top  heavy,  and  is  apt  to  slip. 

It  is  sometimes  supposed  that, 
provided  that  the  compress  be  placed 
over  the  artery,  it  makes  no  differ- 
ence to  what  part  of  the  limb  the 
tourniquet  plate  is  applied.  This  is 
aii  error,  as  can  be  readily  perceived 
by  reflecting  upon  the  mechanism  of 
the  instrument.  The  tourniquet  is 
so  arranged  that  it  makes  direct  pres- 
sure but  at  two  points  ;  immediately 
below  the  plate,  and  at  a  point  dia- 
metrically opposite ;  at  every  other 
point  of  the  circumference  the  pressure  produced  by  tightening  the  strap  is 
oblique  or  gliding.  Hence  the  inevitable  effect  of  placing  the  plate  elsewhere 
than  either  immediately  over  the  artery,  or  diametrically  opposite  to  it,  will 
be  to  push  the  vessel  more  or  less  to  one  side,  when  the  circulation  may  not 
be  controlled  though  the  instrument  be  applied  as  tightly  as  possible.    Hence, 


The  modern  tourniquet. 


Fig.  106 


Fig.  107. 


'I'll''  li'-ld  tourniquet. 


Signoroni's  horse-shoe  tourniquet. 


whenever  i1  is  practicable^he  tourniquet  plate  should  bo  fixed  as  above  directed, 
immediately  over  the  artery;  when  this  cannot  be  conveniently  done,  as  in  the 
case  of  the  axillary,  or  in  that  of  the  popliteal  artery,  it  should  be  placed  at  a 
poinl  diametrically  opp6site,  over  the  point  of  the  shoulder  in  the  case  of  the 
former,  and  just  above  the  patella  in  that  of  the  latter  vessel. 

Various  other  forms  of  tourniquet  have  been  devised  by  surgeons,  but  none 


INSTRUMENTS    REQUIRED    FOR    AMPUTATION. 


567 


of  them  approach  in  value  to  the  familiar  instrument  of  Petit.  The  field 
ton n liquet  (Fig.  106),  numbers  of  which  are  sometimes  distributed  to  troops 
in  time  of  war,  consists  merely  of  a  strap  and  buckle,  with  a  pad  to  go  over 
the  artery;  unless  very  firmly  applied,  it  is  apt  to  do  harm  rather  than  good 
by  obstructing  the  venous,  without  controlling  the'arterial  circulation,  and  is 
certainly  inferior  to  the  Morel  tourniquet  or  Spanish  windlass.  Other  instru- 
ments, which  seem  to  me  better  adapted  for  the  compression  treatment  of 
aneurism,  or  for  temporary  employment  in  cases  of  accidental  hemorrhage, 
than  for  use  in  amputations,  are  the  horse-shoe  or  SignoronVs  tourniquet  (Fig. 
107),  Skey's  tourniquet  (Fig.  108),  Hoey's  clamp1  (Fig.  109),  and  Gross's  arterial 

Fig.  108.  Fig.  109. 


Skey's  tourniquet. 


Hoey's  clamp. 


compressor  (Fig.  110).  Under  certain  circumstances,  however,  as  when  it  is 
desired  to  compress  the  abdominal  aorta  or  common  iliac  artery  preparatory 
to  amputating  at  the  hip-joint,  the  Petit's  tourniquet  is  inapplicable ;  and 
here  the  greatest  benefit  may  be  derived  from  the  use  of  one  of  these  other 


Fie.  110. 


Gross's  arterial  compressor. 


instruments.  The  compressor  first  employed  in  this  operation  by  Prof.  Jose]  ih 
Pancoast,  and  since  frequently  used  in  this  city  (Philadelphia)  for  hip-joint 
amputations,  was  a  large-sized  Skey's  tourniquet,  to  which  Prof.  Pancoast 
added  a  second  pad  (Fig.  Ill),  so  as  to  make  very  deep  and  firm  pressure 


1  This  instrument  is  sometimes  credited  to  Dupuytren. 


568 


AMPUTATIONS. 


upon  the  aorta. 

former" 

aclap 

is  the  one  generally  employed  in  England.     I  have  used  both  in  amputating 

at  the  hip-joint,  and  have  no  hesitation  in  declaring  my  preference  for  Prof. 

Lister's  instrument,  as  being  much  simpler  and  more  readily  adjusted  than 

the  other. 


Fig.  111. 


Fig.  112. 


Pancoast's  abdominal  tourniquet. 


Lister's  aortic  compressor. 


There  have  always  been,  and,  probably,  always  will  be,  two  schools  in 
operative  surgery :  that  which  makes  light  of  the  loss  of  blood,  looking  upon 
it  as  a  trilling  matter,  and  that  which  deprecates  any  unnecessary  expenditure 
of  the  "  vital  fluid,"  considering  every  drop  that  can  be  saved  as  of  value  to 
the  patient.  Hence  we  find  that  some  surgeons  have  objected  to  the  use  of 
the  tourniquet  in  amputation,  preferring  to  rely  exclusively  upon  compression 
of  the  main  artery  by  the  fingers  of  an  assistant.  It  is  said  that  the  tourni- 
quet produces  venous  congestion,  and,  in  the  circular  operation,  interferes  with 
the  necessary  muscular  contraction ;  and  of  late  years  it  has  been  imagined 
that,  by  inducing  venous  thrombosis  at  the  point  of  application,  it  predis- 
poses to  the  occurrence  of  pyaemia.  The  last-mentioned  objection  is  hardly 
worthy  of  serious  consideration  :  if  venous  thrombosis,  per  sc,  were  the  cause 
of  pyaemia,  we  should  have  pyremic  complications  in  almost  all  cases  of  sim- 
ple fracture.  By  taking  care  to  elevate  the  limb,  or  even  to  surround  it  with 
a  firm  bandage  applied  from  below  upwards,  before  screwing  down  the  tourni- 
quet, the  interference  with  the  venous  circulation  may  be  reduced  to  a  mini- 
mum;  and  nothing  can  be  easier  than  to  saw  off  an  additional  piece  of  bone, 
after  securing  the  vessels,  if  the  retraction  of  the  muscles  should  render  it 
necessary.  Guthrie  and  Hennen  speak  of  the  operator  compressing  the  artery 
with  one  hand  while  he  amputates  with  the  other;  but  such  unnecessary  feats 
seem  to  me  rather  adapted  to  exhibit  the  skill  and  boldness  of  the  surgeon 
than  to  promote  the  welfare  of  the  patient.  Safety  should  never  be  sacrificed 
to  brilliancy,  and  there  can  be  no  doubt  that  a  well-applied  tourniquet  renders 
an  amputation  safer  than  the  best  directed  manual  pressure;  for  while  this 
can  only  arrest  the' flow  of  blood  through  the  main  trunk,  the  tourniquet 
controls  all  the  arteries  at  once,  and  it  is  often  the  smaller  vessels  that  give 
the  most  trouble. 


INSTRUMENTS    REQUIRED    FOR    AMPUTATION. 


569 


Esmarch's  Apparatus.— I  have  already  mentioned  the  plan  of  elevating 
the  limb  and  bandaging  it  from  below  upwards,  before  screwing  down  the 
tourniquet,  in  order  to  prevent  the  loss  of  venous  blood  besides^controllino- 
arterial  hemorrhage.  An  improvement  upon  this  procedure  has  been  intro- 
duced within  a  few  years  by  an  Italian  surgeon,  Silvestri,  and  by  Esmarch 
an  eminent  surgeon  of  Kiel.  Esmarch's  apparatus  (Figs.  113, 114)  consists  of 
a  gum-elastic  bandage  and  tube.     The  bandage  is  accurately  applied  to  the 


Fie.  113. 


Fie.  114. 


Esmarch's  elastic  bandage. 


Esmarch's  elastic  tube. 


limb  upon  which  the  operation  is  to  be  performed,  from  below  upwards,  and 
with  sufficient  firmness  to  render  the  part  quite  bloodless.     The  elasticity  of 
the  bandage  renders  it  unnecessary  to  make  reverses,  and  with  a  little  care 
the  whole  extremity  can  be  covered  in  without  leaving  any  gaps  between 
the  turns.     The  tube,  which  may  be  either  round  or  flattened  (as  in  Fig.  114), 
is  next  wound  firmly  four  or  five  times  around  the  limb,  at  the  point  of  ter- 
mination of  the  bandage,  and  is  secured  either  by  tying  or  by  a  hook  and 
chain.     The  bandage  being  then  removed,  the  part  is  left  fully  exposed,  and 
entirely  free  from  blood.     In  the  early  days  of  "  artificial  ischaemia,"  as  this 
method  of  rendering  a  limb  bloodless  has  been  called,  an  India-rubber  cord 
was  sometimes  used  instead  of  the  tube,  thus  making  much  firmer  constric- 
tion than  was  really  necessary,  and  leading  in  some  cases  to  paralysis  or  even 
gangrene  of  the  limb  to  which  it  was  applied,  while  in  other  instances  the 
pressure  of  the  bandage,  by  dislodging  clots  and  forcing  them  upwards  into 
the  larger  veins,  caused,  it  is  said,  pulmonary  embolism  and  death.     But  the 
principal  objection  that  has  been  urged  against  the  employment  of  Esmarch's 
apparatus  is  the  liability  to  consecutive  hemorrhage.    There  is  no  doubt  that, 
unless  special  precautions  be  observed,  free  capillary  oozing  will  inevitably 
follow  when  the  tube  is  removed,  and  in  some  cases  this  may  prove  a  wit 
serious  complication :  thus  I  am  cognizant  of  one  case  in  which,  after  the  use 
of  the  tube  and  bandage  in  an  excision  of  the  knee-joint,  capillary  bleeding 
began  when  the  tube  was  removed,  and  continued  until  the  patient's  death. 
Various  plans  have  been  adopted  to  prevent  this  oozing:    Xicaise  advises 
compression  of  the  wound  with  a  sponge  dipped  in  a  two-per-cent.  solution 
of  carbolic  acid  ;  Riedinger  applies  to  the  wound  a  current  of  induced  elec- 
tricity ;  and  Esmarch  himself  recommends  that,  after  tying  all  the  vessels 
that  can  be  found,  the  wound  should  be  closed  with  deep  sutures,  dressed, 
and  elevated  to  a  vertical  position  before  the  tube  is  removed,  and  that  this 
position  should  be  maintained  for  at  least  half  an  hour  afterwards. 

The  plan  which  I  have  myself  adopted,  and  which  I  can  confidently  recom- 
mend as  being  less  troublesome,  and  at  least  as  satisfactory,  as  any  of  those 
that  have  been  mentioned,  is  based  upon  a  consideration  of  the  cause  of  the 
capillary  oozing  referred  to.  The  firm  pressure  of  the  elastic  tube,  if  con- 
tinued for  more  than  a  very  short  time,  produces  temporary  paralysis  of  the 


570  AMPUTATIONS. 

vasomotor  nerves  of  the  part  affected,  and,  as  a  consequence,  dilatation  of  all 
the  vessels ;  the  normal  contraction  and  retraction  of  these  does  not  take 
place,  and,  when  the  tube  is  removed,  profuse  bleeding  occurs  and  continues 
until  the  vessels  regain  their  natural  tone.  Xow,  except  in  cases  of  necrosis, 
etc.,  in  which  the  bleeding  can  be  restrained  by  firmly  stuffing  the  wound 
with  lint  before  the  removal  of  the  tube,  it  is  evident  that,  in  order  to  pre- 
vent hemorrhage,  the  arterial  circulation  should  still  be  controlled  after  the 
tube  has  been  taken  off,  and  while  the  vessels  are  recovering  themselves. 
This  may  be  conveniently  and  effectively  done  by  combining  the  use  of  the 
tube  with  that  of  the  ordinary  tourniquet.  My  plan  is  to  place  a  tourniquet 
in  position,  but  not  screwed  down,  over  the  main  artery  of  the  limb,  and 
then  to  apply  the  Esmarch  tube  a  few  inches  above  the  point  at  which  I 
intend  to  amputate.  As  soon  as  the  principal  vessels  have  been  secured — 
and  these  should  be  readily  recognized  through  a  knowledge  of  their  ana- 
tomical relations— the  tourniquet  plate  is  screwed  down  and  the  tube  removed. 
No  bleeding  follows,  because  the  circulation  is  still  thoroughly  controlled  by 
the  tourniquet,  and  by  the  time  that  the  remaining  arteries  requiring  liga- 
tures have  been  tied,  the  vessels  will  have  regained  their  tone,  and  the  tour- 
niquet can  be  withdrawn  without  any  risk  of  bleeding  following. 

In  amputations  for  injury,  where  there  is  much  laceration  of  the  tissues,  I 
commonly  apply  the  Esmarch  tube  without  the  elastic  bandage ;  in  amputa- 
tions for  disease,  however,  or  where  there  is  not  much  laceration,  and,  gene- 
rally, in  operations  other  than  amputation,  both  should  be  employed.  Apart 
from  the  very  great  convenience  to  the  surgeon,  in  many  cases,  of  having  the 
field  of  operation  free  from  blood  during  his  manipulations,  I  am  well  con- 
vinced that  the  judicious  use  of  Esmarch's  method  will  enable  a  certain 
number  of  lives  to  be  saved  by  operation,  which  would  otherwise  inevitably 
be  lost. 

Various  ingenious  modifications  of  Esmarch's  apparatus  have  been  sug- 
gested by  Foulis,  II.  L.  Browne,  C.  B.  Nancrede,  and  other  surgeons ;  but  I 
have  no  personal  experience  of  any  of  these  devices,  of  the  practical  value  of 
which  I  confess  to  have  some  doubts.  M.  Houze  de  l'Aulnoit  employs  a 
simple  band  of  caoutchouc,  applied  while  the  limb  is  held  in  a  vertical  posi- 
tion, and  dispenses  with  the  preliminary  bandage. 

Amputating  Knives. — The  knife  formerly  used  for  the  circular  operation 
had  but  one  edge  and  a  very  heavy  back,  being  shaped  somewhat  like  a  sickle 
(Fig.  115);  and  a  very  good  knife  it  was,  cutting  through  the  soft  tissues 

Fig.  115. 


Old  knife  for  circular  amputations. 


almost  by  its  own  weight,  and  doing  its  work  in  a  very  satisfactory  man- 
ner. The  modern  amputating  knives,  however,  which  are  intended  for 
use  in  either  the  circular  or  the  flap  operation,  have  a  sharp  point  and  are 
usually  double-edged  for  an  inch  or  more  at  the  extremity  (Figs.  116,  117). 
The  length  of  the  Knife  should  be  about  one  and  a  half  times  the  diameter  of 
the  limb  to  be  removed,  and  its  breadth  from  three-eighths  to  three-fourths 
of  ;in  inch.  Thus  a  knife  with  a  cutting  edge  of  eight  or  nine  inches  will 
be  sufficiently  long  for  most  amputations  of  the  thigh,  while  one  with  an 
edge  <>f  six  or  seven  inches  will  be  ample  for  smaller  limbs.  Double-edged 
cauina  (Fig.  118)  are  used  principally  for  the  forearm  and  leg,  and  are  con- 


INSTRUMENTS    REQUIRED    FOR    AMPUTATION. 


571 


venient  in  clearing  the  interosseous  space  for  the  application  of  the  saw  ; 
their  breadth  should  not  be  greater  than  three-eight] is  of  an  inch.  In  addi- 
tion to  the  amputating  knives  which  have  been  described,  the  surgeon  should 


Figs.  116,  117. 


Modern  amputating  kuives. 


Fig.  llf 


Double-edged  catlin. 


be  provided  with  one  or  more  strong  bistouries  or  scalpels  (Tigs.  119,  120), 
which  should  be  about  three  inches  in  length,  while  for  removi^s:  the  finsrers 

Figs.  119,  120. 


Bistoury  aud  scalpel. 


it  will  be  found  advantageous  to  employ  a  very  slender  knife  with  a  heavy 
back  (Fig.  121).     Two  inches  in  length  and  an  eighth  of  an  inch  in  width 

Fig.  121. 


Knife  for  finger  amputations. 

may  be  considered  suitable  dimensions  for  the  blade  of  sucll  an  instrument. 
These  measurements  are  rather  smaller  than  those  ordinarily  given  in  works 
on  Operative  Surgery,  but  they  are  such  as  my  own  experience  leads  me  to 
recommend.  Indeed,  for  my  own  part,  I  greatly  prefer  a  small  knife  to  a 
large  one,  and  not  unfrequently  employ  what  is  called  a  "  metacarpal  knife.*' 
with  a  three-inch  blade  (Fig.  122)  for  the  largest  amputations,  having  found 

Fig.  122. 


Metacarpal  knife. 

it  amply  sufficient  even  for  disarticulation  at  the  hip-joint.  The  handles  of 
amputating  knives  should  be  large  enough  to  afford  a  firm  grasp,  and  if 
made  of  roughened  ebony  are  less  likely  to  slip  than  if  of  bone  or  ivory. 

Saws. — The  principal  varieties  of  saw  used  for  amputations  are  the  ordi- 
nary flat-bladed  saw  (Fig.  123)  and  the  bow  saw  (Fig.  124),  of  which  my  own 


572 


AMPUTATIONS. 


preference  leads  me  to  recommend  the  former.    It  should  be  about  ten  inches 
long,  with  a  width  of  two  inches  and  a  half,  should  be  very  strong,  and  should 


Fig.  123. 


W^f*M*>»-«*'-*>»***************'**J 


Amputating  saw. 


be  furnished  with  a  heavy  back,  so  as  to  afford  additional  firmness.     The 
teeth  should  not  be  too  widely  set — -just  enough  to  prevent  the  instrument 


Fig.  124. 


Bow  saw. 


from  binding  as  it  passes  through  the  bone.     A  small  saw,  with  a  movable 
back  (Fig.  125),  will  sometimes  be  found  useful  for  amputations  through  the 


Fig.  125. 


Small  saw  with  movable  back. 


hand  or  foot.  Other  forms  of  saw  have  been  recommended  for  use  in  the 
operation  of  amputation,  among  which  I  may  particularly  mention  the  instru- 
ments which  bear  the  names  of  Rust  and  Butcher  (Figs.  126,  127).     The 

Fig.  126. 


Rust's  saw. 


former  seems  to  me  to  present  no  advantage  over  the  ordinary  saw,  while  the 
latter,  though  almost  indispensable  in  certain  excisions,  as  of  the  knee,  appears 


INSTRUMENTS    REQUIRED    FOR    AMPUTATION. 


573 


to  be  less  well  adapted  for  amputations  ;  it  has  been  claimed  for  it,  as  in  its 
favor,  that  its  use  enables  the  surgeon  to  saw  the  bone  in  a  curved  direction; 


Fig.  127. 


Butcher's  saw. 

but  I  confess  that  I  regard  such  a  mode  of  dividing  the  bone  as  undesirable, 
and  as  unnecessarily  incurring  the  risk  of  necrosis  and  subsequent  exfoliation. 

Cutting  Pliers  or  Bone-nippers  (sometimes  known  as  Liston's  forceps) 
are  used  in  amputations  for  the  purpose  of  removing  any  rough  or  splintered 
edges  left  by  the  saw,  or,  in  operations  on  the  hands  or  feet  for  dividing  the 
phalanges  or  the  bones  of  the  metacarpus  or  metatarsus.  The  whole  length 
of  the  instrument  may  be  from  ten  to  twelve  inches  (Fig.  128),  of  which  not 

Fig.  128. 


Liston's  cutting  bone  forceps. 

more  than  two  inches  should  be  occupied  by  the  blades.  The  latter  should 
be  sharp,  and  may  conveniently  be  set  at  an  obtuse  angle  to  the  handles, 
which  should  be  very  strong  and  roughened,  so  as  to  obviate  any  danger  of 
the  hand  slipping. 

Strong  Forceps  for  holding  a  projecting  extremity  of  bone  are  useful  in 
cases  in  which  amputation  is  rendered  necessary  by  avulsion  of  a  limb,  or  by 

Fig.  129. 


Fergusson's  lion-jawed  forceps. 


a  compound  fracture  in  which  the  injury  of  the  soft-tissues  is  so  extensive 
that  the  assistant  charged  with  steadying  the  part  to  be  removed,  cannot 


574 


AMPUTATIONS. 


obtain  a  firm  grasp  ;  often,  too,  particularly  in  the  circular  operation,  after 
the  vessels  have  been  secured  and  the  tourniquet  removed,  it  may  be  thought 
desirable  to  take  away  an  additional  segment  of  bone,  and  then  it  will  greatly 
facilitate  the  surgeon's  manipulations  with  the  saw,  if  an  assistant  holds  the 
projecting  end  of  bone  with  strong  forceps.  An  excellent  instrument  for  this 
purpose  is  the  "lion-jawed"  forceps  of  Sir  William  Fergusson  (Fig.  129). 
Another,  still  more  powerful  form  of  instrument,  which  bears  the  name  of 
Farabeuf,  is  shown  in  Fig.  130. 

Fig.  130. 


Farabeuf  s  forceps. 


Artery  Forceps  and  Tenacula  are  employed  to  take  up  the  cut  arteries 
(and  veins,  too,  if  they  bleed),  preparatory  to  tying  them.     The  best  form  of 

Fig.  131. 


Cross-spring  forceps. 


forceps  is  that  shown  in  Fig.  131,  the  blades  crossing,  and  being  kept  shut  by 
their  own  spring  ;  the  blades  themselves  should  be  expanded  a  little  way 

Fig.  132 


Catch  forceps. 


above  the  points,  so  that  when  the  ligature  is  applied  it  may  readily  slip 
down  without  including  the  ends  of  the  instrument  itself  in  the  knot.    Other 

Fig.  133. 


Slide  forceps. 


v:iii  cties  of  forceps  are  made  to  fasten  with  a  catch  (Fig.  132),  or  with  a  slide 
(Fig.  133),  but  the  spring  forceps  arc  much  the  best.     All  of  these  varieties 


INSTRUMENTS    REQUIRED    FOR    AMPUTATION. 


0  iO 


are  included  under  the  generic  name  of  the  "  bull-dog"  forceps,  the  invention 
of  which  is  attributed  to  the  late  Mr.  Liston. 

Dr.  Hodgen,  of  St.  Louis,  has  devised  an  ingenious  form  of  artery  forceps 
by  which  the  vessel  is  drawn  from  its  sheath  by  the  weight  of  the  instrument, 
a  cutting  slide  serving  afterwards  to  divide  the  ligature,  and  thus  enabling 
the  operator  to  tie  the  artery  without  the  help  of  an  assistant. 

The  tenaculum,  or  sharp  hook  (Fig.  134)  is,  upon  the  whole,  not  so  conve- 
nient an  instrument  as  the  forceps,  though  invaluable  in  certain  eases,  as 

Fig.  134. 


Tenaculum. 


Fig.  135. 


when  the  parts  are  matted  together  by  inflammatory  action  of  long-standing, 
so  that  the  vessels  cannot  be  readily  seized  by  the  forceps,  or  when  an  artery 
bleeds  in  close  proximity  to  the  bone.  In  some  cases  it  is  even  necessary  to 
take  up  a  mass  of  tissue,  including  the  vessel,  with  two  tenacula,  and  throw  a 
ligature  around  the  whole,  withdrawing  the  second  tenaculum  before  the  knot 
is  finally  tightened.  Though  I  have  very  often  practised  this  ligature  en 
masse,  and  have  never  seen  any  evil  consequence  result  from  it,  yet  it  is  better 
when  practicable  to  draw  each  vessel  a  little  way  from  its  sheath,  and  tie  it 
separately.  The  tenaculum  should  be  of  sufficient  size — an 
inch  to  an  inch  and  a  quarter  in  the  transverse  portion  of 
the  hook — and  not  too  much  curved. 

Besides  the  artery  forceps  which  have  been  described,  the 
surgeon  will  do  well  to  have  in  readiness  some  serre-jines 
(Fig.  135)  and  spring-clips  (Figs.  136, 137),  which  are  known 
here  by  the  name  of  the  late  Mr.  Xunneley.  These  are 
particularly  convenient  in  case,  after  the  removal  of  the 
tourniquet,  several  points  should  be  seen  bleeding  simul- 
taneously. These  clips  can  be  quickly  applied,  so  as  to 
control  the  hemorrhage  temporarily,  and  then  removed  one  by  one  as  the 
surgeon  is  ready  to  supply  their  place  by  ligatures. 


Fig.  136. 


Fig.  137. 


Nunneley's  clips. 

Ligatures  may  be  made  from  a  great  variety  of  materials,  such  as  catgut, 
horsehair,  or  other  animal  substances,  silver  or  iron  wire,  or,  which  I  much 
prefer,  fine  whip-cord  or  strong  silk:.  Animal  ligatures  were  employed  by  Sir 
Astley  Cooper  and  by  Dr.  Physiek,  and  in  the  form  of  the  carbolized  catgut 
ligature  have  been  revived  by  Prof.  Lister  and  his  followers,  and  are  habitu- 
ally used  by  those  surgeons  who  employ  the  so-called  "antiseptic  method." 
The  late  Prof.  Eve,  of  Nashville,  thought  highly  of  a  ligature  made  from  the 
sinew  of  the  deer,  and  Mr.  Barwell  has  employed  ligatures  from  the  middle 
coat  of  the  aorta  of  the  ox,  and  Mr.  T.  Smith  and  Mr.  Croft  those  from  the 
tendon  of  a  kangaroo.  Metallic  ligatures  were  used,  about  fifty  years  ago,  in  a 
number  of  experiments  on  the  lower  animals  by  Dr.  Levert,  of  Alabama, 


576  AMPUTATIONS. 

and  similar  experiments  have  been  since  repeated  by  Sir  J.  Y.  Simpson  and 
by  Dr.  B.  Howard,  of  New  York.  While  both  animal  and  metallic  ligatures 
have  been  employed  in  operations  upon  the  human  subject  with  sufficient 
frequency  to  leave  no  doubt  as  to  their  safety  and  efficiency,  I  have  seen  no 
evidence  to  make  me  think  them  in  any  way  better  than  the  hempen  or 
silken  ligatures  which  are  more  generally  employed.  Indeed  silk  (which, 
however,  is  itself  an  animal  substance)  seems  to  me,  upon  the  whole,  the  best 
material  from  which  a  ligature  can  be  made.  It  can  be  carbolized,  if  the 
surgeon  wish,  and  in  this  form  was  at  one  time  used  by  Prof.  Lister,  and  was 
preferred  to  catgut  by  the  late  Mr.  Maunder.  Silk  is  now  prepared  for  the 
surgeon's  use  by  plaiting  the  strands  instead  of  twisting  them,  and  the  plaited 
ligature  has  the  advantage  of  much  greater  strength  as  well  as  of  greater 
readiness  in  application.  Silk  ligatures  should  be  about  eighteen  inches  in 
length,  the  ordinary  skein  of  silk  which  contains  about  six  yards  thus  suf- 
ficing for  twelve  ligatures.  Before  using  the  silk,  it  should  be  well  waxed, 
that  the  ligatures  may  not  become  entangled  with  each  other,  and  that  they 
may  not  slip  in  the  surgeon's  hands.  In  applying  a  ligature,  the  bleeding 
vessel  is  caught  and  drawn  a  little  forward  with  either  the  artery  forceps  or 
the  tenaculum,  and  an  assistant  then  throws  the  thread  around  it  and  secures 
it  with  a  double  knot.  The  ligature  should  be  tightened  by  a  firm  and  steady 
pull,  without  any  jerking  movement ;  the  first  knot  should  be  made  with  suf- 
ficient force  to  divide  the  inner  and  middle  coats  of  the  artery,  and  the  second 
knot  adjusted  so  as  to  prevent  the  first  from  slipping ;  if  catgut  or  horsehair 
be  employed,  a  third  knot  is  desirable.  The  best  form  of  knot  is  that  known 
by  sailors  as  the  "reef-knot"  (Fig.  138);  it  is  much  to  be  preferred  to  either 
the  "  granny"  (Fig.  140)  or  the  "  surgeon's  knot"  (Fig.  139). 

Fig.  138.  Fig.  139.  Fig.  140. 


The  "reef"  or  "Bailor's"  knot.  The  "  surgeon's"  knot.  The  "granny"  knot. 

It  is  customary,  when  many  ligatures  are  applied,  to  cut  off  one  end  of 
each  and  bring  the  other  end  out  at  any  convenient  part — usually  one  angle — 
of  the  wound.  For  purposes  of  distinction,  both  ends  of  the  ligature  which 
surrounds  the  main  artery  may  be  left  and  knotted  together.  It  has  been 
proposed  to  bring  each  ligature  out  separately  by  an  independent  opening 
through  the  covering  of  the  stump,  so  as  to  allow  the  edges  of  the  wound  to 
come  in  contact  throughout  their  whole  extent,  without  interruption ;  but 
apart  from  the  inconvenience  and  delay  which  would  be  caused  by  such  a 
mode  of  procedure,  the  ligature  ends  themselves,  being  brought  out  in  one 
or  two  groups, 'serve  a  useful  purpose  by  affording  an  excellent  means  of 
drainage.  Short-cut  ligatures — that  is,  with  both  ends  cut  short — were  much 
employed  by  Ilcuncn  and  a  few  other  surgeons  in  the  early  part  of  this  cen- 
tury, and  have  been  revived  in  connection  with  the  "antiseptic  method"  by 
Prof.  Lister  and  his  followers.  If  short-cut  ligatures  are  used,  a  perforated, 
India-rubber  drainage  tube  must  be  employed  to  allow  the  escape  of  the 


INSTRUMENTS    REQUIRED    FOR    AMPUTATION.  577 

fluids  which  are  always  poured  out  in  an  amputation-wound  after  the  opera- 
tion, but  if  the  ordinary  form  of  ligature  be  adopted,  the  drainage  tube  La 
usually  unnecessary.  Other  means  of  checking  the  bleeding  after  amputa- 
tion, such  as  acupressure  or  "some  of  its  modifications — filo-pressure,  etc. — or 
torsion,  may  be  employed,  and  each  method  is  advocated  by  excellent  sur- 
geons. These  will  be  fully  described  in  the  article  on  Injuries  of  Blood- 
vessels, in  a  subsequent  volume,  and  need  not  be  further  considered  here.  I 
have,  however,  no  hesitation  in  expressing  the  opinion  that  the  ligature  is 
more  valuable  than  all  of  its  substitutes  put  together,  and  is  certainly  prefer- 
able as  a  means  of  arresting  hemorrage  after  the  operation  of  amputation. 

The  Retractor  is  an  important  part  of  the  necessary  apparatus  for  an 
amputation,  and  its  value,  as  has  been  already  mentioned,  was  fully  recog- 
nized by  the  surgeons  of  antiquity.  It  consists  of  a  piece  of  stout  muslin, 
six  or  eight  inches  wide  and  three  or  four  feet  long,  one  end  being  split  to 
the  middle  into  two  tails  for  amputations  of  the  upper  arm  and  thigh,  and 
into  three  tails  for  those  of  the  forearm  and  leg  below  the  knee.  In  the 
former  case  the  tails  are  wound  around  the  bone,  and  crossed ;  in  the  latter, 
the  middle  tail  is  thrust  between  the  bones  and  the  others  are  disposed  of  as 
before  ;  both  ends  of  the  retractor  are  then  grasped  by  an  assistant  and  firmly 
drawn  upwards,  so  as  to  answer  the  double  purpose  of  retracting  the  muscles 
from  the  bone  and  of  protecting  the  soft  parts  from  being  injured  by  the  saw. 
The  muslin  retractor  is  made  fresh  for  every  case;  certainly  a  cleaner  and 
better  plan  than  to  use  the  leather  retractor  of  Gooch^Bromfeild,2  and  others 
of  our  predecessors. 

Sutures. — Great  diversity  of  opinion  has  prevailed  at  different  times  as  to 
the  propriety  of  using  sutures  in  the  dressing  of  amputation  wounds.  The 
ancients  employed  them  as  one  of  the  means  of  arresting  hemorrhage,  and 
they  continued  to  be  thus  used  until  the  general  adoption  of  the  ligature;  and 
the  eminent  surgeon  of  Guy's  Hospital,  Samuel  Sharp,  or  Sharpe — he  spelt 
his  name  both  ways — revived  the  use  of  the  "cross-stitch"  (an  old  device 
employed  by  Pare  and  Wiseman),  to  prevent  retraction  of  the  soft  parts  and 
consequent  protrusion  of  the  bone,  and  in  both  his  "Treatise  on  the  Opera- 
tions of  Surgery,"  and  his  "Critical  Enquiry,"  lauded  it  as  not  less  valuable 
for  this  purpose  than  the  "double  incision"  of  Petit  and  Cheselden.  <  (ther 
surgeons  have  reprobated  the  use  of  sutures  altogether,  preferring  to  secure 
approximation  of  the  edges  of  the  wound  by  the  use  of  compresses  and 
bandages,  or  by  the  employment  of  adhesive  plaster.  There  can  certainly  be 
nothing  more  injudicious  than  to  sew  up  a  stump  tightly,  as  if  to  hermetically 
seal  it,  without  making  any  provision  for  the  escape  of  effused  fluids,  <»r 
allowing  for  the  unavoidable  occurrence  of  swelling;  such  a  mode  of  dressing 
the  wound  will,  in  the  course  of  a  few  hours,  probably  send  up  the  patient's 
pulse  and  temperature  in  an  early  development  of  traumatic  fever,  and  it  will 
be  fortunate  if  the  mistake  is  discovered  in  time  to  cut  out  the  offending 
stitches  before  sloughing  is  inevitable.  But  provided  that  there  is  tissue 
enough  to  cover  the  bone  without  making  tension,  and  that  ample  drainage 
is  afforded  either  by  the  ligature  ends  or  by  the  introduction  of  a  tube,  sutures 
may  be  properly  employed  after  amputation,  and  present,  I  think,  many 
advantages  over  other  methods  of  closing  the  wound. 

The  best  material  for  the  suture  is,  I  think,  silver,  lead,  or  malleable  iron 
wire;  catgut  is  unsatisfactory,  as  not  keeping  its  place  for  a  sufficient  length 

'  Cases  and  Practical  Remarks  in  Surgery,  vol.  ii.  p.  330.     Norwich,  1767. 
2  Chirurgical  Observations  and  Cases,  vol.  i.  p.  152.     London,  1773. 

vol.  i.— 37 


578 


AMPUTATIONS. 


of  time,  while  the  metallic  has  the  great  advantage  over  the  silk  or  hemp 
suture,  that  it  can  be  loosened  by  untwisting,  if  there  be  too  much  tension  of 
the  part,  without  being  entirely  withdrawn.  Indeed  I  make  a  practice,  at 
the  first  renewal  of  the  dressing  after  an  amputation,  of  trying  every  suture 
point  in  succession,  and  untwisting  it  a  little,  if  it  seems  to  be  applied  too 
closely.  The  form  of  suture  adapted  for  amputation  wounds  is  the  interrupted 
suture,  and  its  points  should  be  at  least  half  or  three-quarters  of  an  inch 
apart.  If  silk  be  employed,  it  is  tied  in  a  reef-knot  (as  in  the  case  of  liga- 
tures), but  if  wire  be  used,  it  is  twisted  with  four  or  five  turns,  and  the  ends 
then  cut  smoothly  off;  it  is  well  to  take  the  precaution  of  twisting  all  the 
stitches  in  the  same  direction,  for  greater  convenience  in  untwisting  if  this 
should  be  found  necessary. 

Needles. — The  ordinary  "  surgeon's  needle"  (Fig.  141)  answers  every  pur- 
pose in  introducing  the  sutures  after  amputation,  whatever  material  for  the 

suture  be  employed.  The  needle  should 
be  rather  large,  strong,  and  either 
straight  or  but  slightly  curved.  It 
should  be  provided  with  a  lance-point, 
that  it  may  readily  penetrate  the  tissues, 
and  should  have  a  large  eye  that  it  may 
be  threaded  without  difficulty.  Needles 
are  made,  to  be  used  with  wire,  with  a 
groove  on  either  side  at  the  eyed  end ; 
but  the  wire  very  seldom  rests  in  the 
groove,  and  the  advantage  of  this  modi- 
fication is  more  in  theory  than  in  reality. 
Other  needles  have  been  made  with  a 
female  screw  worked  in  the  blunt  end, 
for  the  wire  to  be  screwed  into  it ;  but  the  wire  is  apt  to  become  detached  at 
inconvenient  moments,  and  upon  the  whole  I  am  disposed  to  regard  the  old- 
fashioned  needle  as  quite  as  satisfactory  as  any  of  its  substitutes.  If  the 
naps  be  unusually  thick,  it  may  be  convenient  to  employ  a  needle  with  a 
handle,  and  an  eye  near  its  point  (Fig.  142),  like  that  employed  in  the  opera- 

Fte.  142. 


J.H.GEMRIG. 

Various  forms  of  needle. 


Needle  with  eye  near  point. 

tion  of  strangulating  a  nsevus.  The  wire  with  which  a  needle  is  armed 
should  be  about  eighteen  inches  long,  and  should  be  passed  through  the  eye 
for  an  inch  or  an  inch  and  a  quarter  of  its  length,  and  then  folded  evenly 
upon  itself,  without  twisting  ;  its  thickness  should  be  in  proportion  to  the  size 
and  weight  of  the  flaps  which  it  is  intended  to  hold  together,  and  it  should 
be  flexible  and  smooth,  and  quite  free  from  kinks. 

Fig.  143. 


Dissecttno  Fokcei'S  (Fig.  143)  are  employed  to  si >ize  projecting  nerves  or 
tendons  which  may  require  to  lie  cut  oil,  and  to  aid  in  adjusting  the  sutures. 


OPERATIVE    METHODS    EMPLOYED    IX    AMPUTATION.  579 

Scissors  of  various  sizes  and  shapes  are  used  in  an  amputation.  There 
should  be  one  pair,  strong,  and  with  blades  set  at  an  angle  (Fig.  144;,  for 
cutting  plasters  and  bandages;  a  pair  of  ordinary  "surgical  scissors,"  sharp 

144.  Fig.  145. 


o 


Bandage  scissors.  Scissors  curved  on  the  flat. 

and  strong,  for  cutting  ligatures  and  sutures;  and  a  third  pair,  with  blades 
curved  on  the  fiat  (Fig.  145),  also  sharp  and  strong,  for  retrenching  protruding 
nerves,  tendons,  and  masses  of  fascia. 

Besides  the  various  instruments  required  for  an  amputation,  and  the  neces- 
sary dressings,  the  surgeon  should  see  that  there  are  in  readiness  plenty  of 
clean  sponges  of  a  convenient  size;  warm  and  cold  water;  a  hot-water  can 
or  spirit-lamp,  for  boating  strips  of  adhesive  plaster,  if  the  ordinary  officinal 
plaster  is  to  be  employed — what  is  sold  as  the  "  American  Surgeons'  adhesive 
plaster,"  though  somewhat  more  expensive,  is  a  more  convenient  article, 
adhering  without  being  warmed  ;  an  efficient  styptic  for  controlling  capillary 
hemorrhage  ;  and  a  little  white  wax  for  plugging  the  medullary  cavity  of 
the  bone,  if  that  should  be  the  source  of  troubjlesome  bleeding. 


Operative  Methods  Employed  in  Amputation. 

All  the  various  methods  of  amputating  may,  as  heretofore  mentioned,  be 
regarded  simply  as  modifications  of  the  two  principal  modes  already  referred 
to,  the  flap  and  the  circular.  Thus  the  oval  operation,  as  perfected  bv  Scou- 
tetten  and  Malgaigne,  is  a  variety  of  the  circular  method,  while  the  different 
plans  of  Sedillot,  Teale,  Lee,  Stephen  Smith,  etc.,  may  all  be  considered  as 
modifications  of  the  flap  operation. 

Circular  Method. — M.  Fort,  one  of  the  most  recent  French  writers  on 
operative  surgery,  enumerates  no  less  than  seven  varieties  of  the  circular 
operation,  distinguishing  them  as  the  procedures  of  Alanson,  Benjamin  Bell, 
Brunninghausen,  Desault,  Louis,  Malgaigne,1  and  J.  L.  Petit.  The  peculiari- 
ties of  most  of  these  methods  have  been  sufficiently  indicated  in  the  section 
devoted  to  the  History  of  Amputation,2  and  I  may  add  here  that  the  special 
feature  of  Brunninghausen's  plan  consisted  in  dissecting  up  a  cuff  of  skin, 
as  done  by  Hey,  Bell,  and  Alanson,  and  then  cutting  the  muscles  and  bone  on 
the  same  plane,  and  that  of  Malgaigne's  operation  in  combining  the  pecu- 
liarities of  both  Desault's  and  Bell's  'methods,  making  thus  what  he  called  a 
"quadruple  incision."3  The  circular  operation,  as  ordinarily  practised  at  the 
present  day,  is  in  all  essential  particulars  the  operation  of  Hey,  Bell,  and 
Alanson,  and  is  performed  as  follows : — 

The  part  to  be  operated  upon  having  been  washed  and  shaved,  and  the 
patient  being  thoroughly  under  the  influence  of  an  anaesthetic,  he  is  brought 

1  Malgaigne  himself  enumerated  nine  methods,  exclusive  of  his  own. 

2  Vide  supra,  pp.  557,  558. 

3  Manuel  de  medecine  operatoire,  3e  6dit.  p.  290.     Paris,  1S40. 


580  AMPUTATIONS. 

to  the  side  or  foot  of  the  hed  or  operating  table,  in  such  a  way  that  the  limb 
to  be  removed  shall  project  fairly  over  the  edge.  The  patient  should  be  well 
protected  from  the  cold,  and  a  coarse  blanket,  or  a  tray  containing  bran  or  saw- 
dust, should  be  placed  on  the  floor  to  catch  the  blood.  The  circulation  is 
then  to  be  controlled  by  the  adjustment  of  the  tourniquet  with  or  without 
Esmarch's  tube,  as  already  described,  or  in  certain  situations  by  the  pressure 
of  an  assistant's  finger,  or  by  means  of  a  wrapped  key,  as  will  be  particularly 
explained  when  we  come  to  speak  of  amputations  at  the  shoulder.  If  the 
application  of  the  tourniquet  is  entrusted  to  an  assistant,  the  surgeon  should 
at  least  see  for  himself  that  the  compress  is  accurately  placed  over  the  main 
vessel,  and  that  the  strap  is  drawn  sutficiently  tight  for  the  pulsation  of  the 
artery  below  to  be  arrested  by  a  few  turns  of  the  screw.  The  circulation  being 
under  control,  one  assistant  is  deputed  to  take  special  charge  of  the  tourni- 
quet, a  second  to  manage  the  anaesthetic,  and  a  third  to  hold  the  limb  in 
whatever  position  may  be  convenient  for  the  operator.  A  fourth  assistant 
may  hand  the  instruments,  or,  which  I  prefer,  these  may  be  arranged  in  a 
tray  at  the  surgeon's  right  hand,  in  the  order  in  which  they  are  to  be  used, 
so  that  he  may  readily  help  himself.  The  operator  should  stand  with  his 
left  hand  towards  the  patient's  trunk;  thus  in  amputating  the  right  lower 
extremity,  the  surgeon  stands  at  the  patient's  right  side,  while  in  removing 
the  left  leg  or  thigh  he  stands  between  the  patient's  limbs.  In  amputating  the 
right  arm^  he  stands  facing  the  patient's  feet ;  but  in  amputating  the  left  arm, 
he  faces  the  patient's  head. 

Almost  all  of  the  older  surgeons,  beside  the  fillet  or  band  with  which  they 
tried  to  control  the  circulation,  before  the  invention  of  the  tourniquet,  applied 
other  bands,  one  above  and  one  below  the  point  at  which  the  limb  was  to  be 
removed ;  these  were  to  serve  the  triple  purpose  of  numbing  the  patient's 
sensibility,  of  preventing  the  muscles  from  slipping  or  being  jerked  away 
from  the  knife,  and  of  furnishing  a  guide  for  the  surgeon's  incision.  But,  as 
Bichat1  very  justly  observed,  with  a  good  eye  and  a  sharp  knife  (and  every 
surgeon  should  possess  both  of  these),  such  clumsy  helps  to  the  operation  are 
quite  unnecessary. 

In  making  his  first  incision,  the  surgeon  should  steady  and  draw  the  skin 
of  the  patient's  limb  upwards  with  his  left  hand,  while,  stooping  somewhat, 
he  carries  his  right  hand,  holding  the  long  knife,  around  the  limb,  so  that 
the  back  of  the  knife  shall  be  directed  towards  his  own  face.  Sinking  the 
heel  of  the  knife  then  firmly  into  the  flesh,  he  makes  a  circular  sweep  around 
the  part,  rising  as  he  does  so,  and  thus  completes  the  whole,  or  nearly  the 
whole,  of  the  cutaneous  incision  with  one  motion.  A  few  light  touches  with 
the  same  knife,  or  with  a  scalpel,  serve  to  tree  any  points  at  which  the  skin 
may  be  still  adherent,  and  permit  considerable  retraction  to  be  at  once  effected. 
If  the  limb  be  slender,  this  degree  of  retraction  maybe  sufficient,  but  it  is 
usually  necessary  to  dissect  upjby  rapid  strokes  of  the  knife,  a  cuff  of  skin 
and  fascia,  about  half  as  long  as  the  limb  is  thick.  The  first  incision  should 
go  completely  down  to  the  "muscles,  and,  in  dissecting  up  the  cuff,  the  edge 
of  the  knife  should  be  kept  constantly  directed  towards  the  deeper  structures, 
as  otherwise  the  nutritive  vessels  of  the  skin  will  be  endangered,  and  slough- 
ing will  he  apt  to  follow.  If  the  limb  be  conical  (as  in  the  calf  of  the  leg), 
there  will  be  great  difficulty  in  reflecting  the  dissected  cuff,  and  the  surgeon 
will  then  find  advantage  in  making  a  longitudinal  incision  on  one  or  the  other 
side — a  modification  of  the  ordinary  procedure  which  ISedillot2  attributes  to 
Lacauchie.     This  incision  supplies  a  convenient  point  for  bringing  out  the 

1  (Euvres  chirurgicales  do  P.  J.  Desault.     Seoondo  partie,  p.  490.     Paris,  1798. 

2  Traito  de  inedecino  oplratoire,  tomo  i.  p.  3122.     Paris,  1853. 


OPERATIVE   METHODS    EMPLOYED    IN    AMPUTATION. 


581 


ligatures,  and,  if  it  be  made  in  a  somewhat  dependent  position,  servo  also  as 
an  excellent  avenue  for  drainage.  When  the  skin  cuff  lias  been  evenly  dis- 
sected back  to  a  sufficient  height,  the  surgeon  again  applies  the  long  knife, 
as  before,  and  cuts  through  the  muscles  quite  down  to  the  bone.  A  wide 
gap  is  instantly  produced  by  the  retraction  of  the  divided  muscles,  but  it  still 
remains  to  sever  their  attachments  to  the  periosteum,  and  to  push  them  up- 
wards, either  with  the  finger  or  the  handle  of  the  scalpel,  so  as  to  leave  the 
bone  bare  for  the  extent  of  about  two  inches.  If  the  limb  contain  two  boms, 
the  interosseous  tissues  are  divided  with  the  scalpel,  or  with  a  narrow,  double- 
edged  catlin,  and  the  adjoining  surfaces  of  the  bones  cleared  in  the  way 
already  described. 

The  retractor  is  next  adjusted — its  middle  tail,  in  the  case  of  the  forearm 
or  leg,  being  thrust  between  the  bones  with  the  finger,  the  handle  of  a  knife, 
or  a  pair  of  forceps — its  body  carefully  spread  out  over  the  soft  parts,  its  tail- 
crossed,  and  the  whole  firmly  drawn  upwards  by  an  assistant.  The  next  Btep 
is  the  sawing  of  the  bone,  which  is  to  be  done  at  the  highest  point  at  which 
this  has  been  exposed.  (Fig.  14(5.)     Some  writers  lay  great  stress  upon  the 

Fi°r.  146. 


Amputation  of  arm  by  circular  method. 


importance  of  dividing  the  periosteum  with  the  knife,  before  applying  the 
saw  ;  but  I  must  confess,  to  a  belief  that  in  practice  this  is  more  often  talked 
about  than  done.  Tho  saw  should  be  held  lightly  at  first,  and  drawn  hack- 
wards  (from  heel  to  point)  so  as  to  make  a  groove  for  itself,  and  thus  avoid 
splintering  the  bone;  if  there  are  two  bones,  they  are,  usually,  divided 
simultaneously,  or,  if  this  cannot  conveniently  be  done,  the  smaller  before 
the  larger.  Roux  and  Malgaigne  advise,  however,  and  I  think  with  reason, 
that,  in  the  case  of  the  leg,  the  tibia  should  be  divided  first,  and  then  the 
fibula  at  a  point  about  half  an  inch  higher.  It  is  usually  directed  that  the 
saw  should  be  held  vertically,  so  that  the  bone  may  not  he  broken  through 
by  the  weight  of  the  limb  before  its  section  has  been  completed.  For  tire 
same  purpose,  the  assistant  who  has  charge  of  the  limb  should  hold  it  up 
firmly  and  not  allow  it  to  drop,  but  at  the  same  time  should  not  elevate  it  bo 
much  as  to  make  the  saw  bind. 

As  soon  as  the  limb  is  off,  the  surgeon  turns  his  attention  to  the  cut  ves- 
sels, taking  up  first  with  forceps  or  tenaculum  the  principal  arteries,  and 
afterwards  securing  the  muscular  and  other  small  branches,  loosening  the 
tourniquet  for  a  moment,  if  necessary,  that  the  gush  of  blood  may  indicate 
their  position.     If,  as  I  have  advised,  the  Esmarcn  tube  be  used  in  addition 


582  AMPUTATIONS. 

to  the  tourniquet,  the  latter  should  be  screwed  down,  and  the  former  removed, 
as  soon  as  the  principal  vessels  have  been  ligated.  Some  difference  of  opinion 
exists  among  surgeons  as  to  the  advisability  of  tying  veins  after  an  amputa- 
tion ;  while  not  often  necessary,  it  is  so  occasionally,  for  large  veins  will 
sometimes  bleed  profusely  even  after  the  removal  of  the  tourniquet ;  and  the 
risk  of  phlebitis  and  pyaemia  which  was  formerly  supposed  to  be  incurred  by 
tying  a  vein,  has  been  over  and  over  again  shown  to  be  purely  imaginary. 
My  own  practice  is  to  tie  them,  often  indeed  including  the  artery  and  its 
vencs  co mites  in  the  same  ligature,  or,  in  the  case  of  such  a  large  vessel  as  the 
brachial  or  the  femoral,  tying  the  artery  first  separately,  and  then  throwing 
a  second  ligature  around  it  and  the  vein  together.  The  surgeon  having 
secured  all  the  vessels  that  can  be  found  bleeding,  the  surface  of  the  stump  may 
be  washed  with  a  styptic,  in  order  to  check  any  capillary  oozing  which  may 
still  persist ;  various  substances  may  be  used  for  this  purpose,  such  as  the 
"  Aqua  Pagliari,"  or  the  "Aqua  Binelli" — the  former  containing  benzoin  and 
alum,1  and  the  latter  no  less  than  twenty-six  different  astringents  or  aromatics 
of  vegetable  origin2 — or,  which  is  as  efficient  and  at  least  as  convenient  as 
any  other,  simple  diluted  alcohol. 

Before  closing  the  wound,  the  surgeon  examines  the  sawn  end  of  the  bone, 
and,  if  any  projecting  spicula  has  been  left,  cuts  it  off  with  the  pliers;  he  also 
retrenches  any  tendons  or  nerves  that  hang  from  the  end  of  the  stump,  by 
drawing  them  out  with  the  ordinary  dissecting  forceps,  and  snipping  them 
off  with  scissors  curved  on  the  flat.  If  bleeding  proceed  from  the  bone  itself, 
it  may  be  most  conveniently  arrested  by  arming  a  pellet  of  softened  white 
wax3  with  a  wire  (to  facilitate  withdrawal),  and  then  pressing  it  firmly  against 
the  bone  so  as  to  plug  its  medullary  cavity;  the  wax  may  be  removed  at  the 
first  or  second  dressing  of  the  stump,  coming  away  without  difficulty  along- 
side of  the  ligatures.  If  a  vessel  in  the  periosteum  bleed,  and  cannot' be  tied, 
it  may  be  secured  by  acupressure,  applied  either  by  the  Aberdeen  or  "twist" 
method,  or  by  the  third  method  of  Sir  J.  Y.  Simpson. 

The  stump  being  at  length  dry,  the  ligatures  are  disentangled  from  each 
other,  and  brought  out  in  one  or  more  bundles  as  may  be  found  convenient. 
The  skin  cuff  is  then  drawn  down  over  the  face  of  the  stump,  and  the  wound 
is  closed  with  sutures,  converting  the  circular  into  a  linear  incision,  and  in 
any  direction  which  the  operator  may  prefer — horizontal,  oblique,  or  vertical — 
it  makes  very  little  if  any  difference  which  be  chosen. 

Modified  Circular  Operation. — This  mode  of  amputation  (Fig.  147), 
which  affords  an  excellent  stump,  appears  to  have  been  suggested  more  than 
fort\-  years  ago  by  the  late  Mr.  Liston,4  and  was,  with  an  important  modifi- 
cation,  extensively  practised  afterwards  by  the  late  Mr.  Syme.5  Liston's  plan 
was  to  make  two  semilunar  flaps  of  integument  only,  divide  the  muscles  by 
a  circular  incision  where  the  skin  flaps  joined,  and  saw  the  bone  as  in  the 
ordinary  circular  method;  Syme's  modification  consisted  in  dissecting  up  a 
cuff  of  Bkin  for  some  distance  above  the  point  of  junction  of  the  semilunar 
flaps.  In  either  form  the  procedure  may  he  looked  upon  as  an  ordinary  cir- 
cular operation,  in  which  the  cuff  of  skin  has  been  slit  upon  both  sides,  and 
the  angles  trimmed  off'.    It  is  particularly  adapted  for  operations  on  muscular 

1  Bulletin  de  Therapeutique,  t.  xlii.,  ami  Sedillot,  op.  oit.  p.  218. 

2  Bouchardat,  Annuaire  de  Therapeutique  pour  L843,  p.  227. 

3  Riedinger  prefers  a  plug  <>f  oatgut,  while  others  employ  a  pledget  of  lint  or  a  plug  of  wood. 
Wax,  however,  seems  to  me  to  lie  the  best  material. 

4  Elements  <>(  Surgery  (1840),  edited  by  Prof.  S.  I).  Gross,  p.  642.     Philadelphia,  1846. 
6  Principles  of  Surgery,  4th  edition,  pp.  148,  149.     London,  1806. 


OPERATIVE    METHODS    EMPLOYED    IN    AMPUTATION. 


583 


limbs,  where  it  fully  merits  Mr.  Skey's1  encomium,  that  it  "is  really  a  good 
operation,"  and  I  prefer  it  to  any  other  for  amputations  at  or  above  the  middle 
of  the  thigh. 


Amputation  of  thigh  by  modified  circular  method. 


Elliptical  Operation. — This,  which  is  often  spoken  of  as  a  variety  of  the 
oval  method,  and,  on  the  other  hand,  as  a  modification  of  the  operation  by  a 
single  flap,  is  attributed  by  Sedillot,  Guerin,  and  other  French  writers  on 
Operative  Surgery,  to  a  Belgian  surgeon,  Soupart,  of  Liege,  but  was  practised 


Fie.  148. 


Amputation  at  elbow  by  elliptical  method. 

as  an  improvement  on  the  circular  method,  in  amputations  below  the  knee, 
by  Sharpe,2  of  Guy's  Hospital,  in  the  middle  of  the  last  century.  Ir  is  par- 
ticularly adapted  to  amputations  at  the  knee- and  elbow-joints,  and  especially 
the  latter.  (Fig.  148.)  The  incision  constitutes  a  perfect  ellipse,  coming  bel<  m 
the  joint,  on  the  least  vascular  side,  by  a  space  equal  to  the  diameter  of  the 
limb,  and  the  resulting  flap  being  folded  upon  itself,  so  as  to  make  a  short 

i  Operative  Surgerv,  page  309.     Philadelphia,  1  Sol. 

2  Treatise  on  the  Operations  of  Surgery,  page  226.     Ninth  edition.     London,  1  i  69. 


584 


AMPUTATIONS. 


curved  cicatrix  on  the  side  of  the  vessels,  thus  making  an  excellent,  non-ad- 
herent covering  for  the  bone. 

Oval  Opekation. — The  oval  operation,  or  that  of  Scoutetten,  may  be  regard- 
ed as  a  modification  of  the  circular  method,  the  skin  cuff  being  slit  upon 

one  side,  and  the  corners  trimmed  off.  Occasionally 
practised  in  the  latter  part  of  the  last  and  at  the 
beginning  of  this  century,  by  Lassus,  Larrey, 
Guthrie,  and  other  surgeons,  this  mode  of  ampu- 
tating was  first  reduced  to  a  system  by  Scoutetten, 
of  Lille,  in  1827.1  We  may  recognize  two  sub- 
varieties  of  this  operation  (Fig.  149):— 

(1)  Method  of  Scoutetten..— In  this  (Fig.  149,  A), 
an  incision  is  begun  on  the  outer  side  of  the  limb, 
and  carried  obliquely  downwards  for  a  distance 
about  equal  to  its  diameter ;  then  continued  trans- 
versely across  the  inner  side  of  the  limb  (or  that 
which  contains  the  great  vessels),  and  obliquely  up- 
wards again  to  meet  the  first  incision  at  an  acute 
angle.  Or  the  same  object  may  be  accomplished  by 
making  first  two  oblique  incisions,  resembling  an 
inverted  ^,  and  joining  them  below  by  a  transverse 
cut. 

(2)  Method  of  Malgaigne.— This  (Fig.  149,  B), 
which  is  called  by  French  writers  the  operation  en 
raquette,  from  the  "  racket-shaped"  form  of  the 
wound,  is  preferable  as  affording  a  better  cov- 
ering  for    the    bone    at   the    upper  part   of   the 

incision.  Malgaigne  particularly  recommended  this  operation  for  ampu- 
tation of  the  thumb,  but  it  i$  equally  applicable  to  other  parts ;  it  consists  in 
making  a  longitudinal  incision  on  the  outer  side  of  the  limb,  extending  a 
short  distance  above  and  twice  as  far  below  the  point  at  which  it  is  intended 
to  amputate;  the  lateral  branches  of  the  oval  incision  are  made  to  start  from 
the  junction  of  the  middle  and  lower  third  of  the  longitudinal  incision. 

In  both  of  these  varieties  of  the  oval  method,  the  wound  is  brought 
together  in  a  longitudinal  direction,  the  operation  herein  differing  widely 
from  the  elliptical  method  described  above,  in  which  the  resulting  cicatrix  is 
a  transverse  one. 


Amputation  of  fingers  by  oval 
method.  A,  method  of  Scoutetten  ;  B, 
method  of  Malgaigne  (en  raquette). 


Sixole  Flap  Operation. — This  was  the  original  method  of  Lowdham,  and, 
as  improved  by  Verduinand  Garengeot,  may  still  be  occasionally  resorted  to 
with  advantage.  In  most  cases,  no  doubt,  either  the  double  flap  or  the  cir- 
cular operation,  or  <>ne  of  the  modifications  of  the  latter  which  have  already 
been  referred  to,  will  enable  the  surgeon  to  obtain  sufficient  covering  for  the 
bone  while  dividing  it  at  a  lower  point  than  could  be  done  were  the  flap  to 
be  taken  altogether  from  one  side;  but  it  may  well  happen,  in  a  case  of  com- 
pound fracture  or  laceration,  from  violence  by  railway  or  machinery,  or  in  a 
case  <d'  incurable  nicer  from  burn,  frost-bite,  etc.,  that  the  tissues  on  one  side 
of  a  limb  may  be  so  injured  or  diseased  that  they  must  be  inevitably  sacri- 
ficed, while  those  on  the  oilier  side  are  perfectly  healthy,  and  ample  in  extent 
to  furnish  a  good  covering  after  amputation;  under  such  circumstances,  the 

1  Velpeau,  op.  cit.,  tome  ii.  p.  -°>G4.  According  to  Lisfranc  (op.  cit.,  tome  i.  p.  744),  who  always 
liked  to  differ  from  Velpeau,  the  oval  operation  originated  with  Le  Dran  ;  but  1  can  find  no  ac- 
count of  it  in  my  copy  of  the  latter  author's  work  (Paris,  1742). 


OPERATIVE   METHODS   EMPLOYED   IN   AMPUTATION.  585 

surgeon  should  take  his  flap  from  the  sound  part  exclusively,  and  will  thus 
probably  be  enabled  to  preserve  a  greater  length  of  the  affected  limb  than  he 
could  in  any  other  way.  The  circulation  being  controlled  in  the  ordinary 
manner,  the  surgeon,  with  a  strong  and  rather  short  knife,  begins  his  incision 
on  the  lower  surface  (so  that  the  path  of  his  knife  may  not  be  obscured  by 
the  flow  of  venous  blood),  and  marks  out  a  tolerably  square,  or  at  least  not  a 
pointed,  flap,  which  should  embrace,  beside  the  skin  and  fascia,  part  or  all  of 
the  subjacent  muscular  layers,  according  to  the  thickness  of  the  part.  This 
flap  is  rapidly  dissected  up,  and  the  section  of  the  soft  parts  completed  by 
making  a  transverse  or  slightly  curved  incision,  convex  forwards,  through 
the  tissues  on  the  other  side  of  the  limb.  The  bone  is  next  cleaned  by  a  few 
touches  of  the  knife,  the  muscles  pushed  upwards  and  the  retractor  adjusted, 
and  the  amputation  then  completed  as  in  the  circular  method.  The  single 
flap  operation  may  also  be  done  by  transfixing  the  limb  with  a  long  knife, 
and  cutting  from  within  outwards;  but  the  flap  can  be  better  shaped,  by  pur- 
suing the  other  plan,  and  where  there  is  no  superabundance  of  available  tissue, 
as  in  the  cases  which  I  have  supposed,  it  will  certainly  be  preferable.  The 
single  flap  operation  is  thought  by  Prof.  Spence,  of  Edinburgh,  to  be  in  most 
cases  preferable  to  any  other.  It  is  also  employed  by  Carden,  of  Worcester, 
and  by  Wharton,  of  Dublin. 

Double  Flap  Operation. — Of  this  method  we  may  recognize  several  varie- 
ties, as  Ravaton's,  Vermale's,  Sedillot's,  Langenbeck's,  Teale's,  and  Lister's. 

(1)  Ravaton's  meth od  consists  in  making  a  circular  incision  down  to  the  bone, 
and  then  adding  a  longitudinal  incision  on  either  side,  so  as  to  make  two 
flaps,  each  half  the  thickness  of  the  limb.  In  this  form,  the  operation  is 
seldom  if  ever  resorted  to  at  the  present  day,  the  flaps  being  unwieldy,  and 
the  protruding  muscles  causing  an  undesirable  degree  of  tension  when  they 
are  brought  together. 

(2)  Vermale's  method  is  the  ordinary  double-flap  operation  of  modern  times. 
In  employing  this  mode  of  amputating,  most  writers,  following  List  on,1 
advise  that  the  surgeon  should  stand  with  his  left  hand  towards  the  part  to 
be  removed;  my  own  practice,  however,  has  been  to  adopt  the  same  position 
as  that  which  I  have  recommended  for  the  circular  operation,  entrusting  the 
entire  care  of  the  limb  to  an  assistant,  and  keeping  the  left  hand  towards  the 
patient's  trunk,  ready  to  grasp  the  artery  if  by  any  chance  the  tourniquet 
should  slip.  This  plan  is  in  accordance  with  the  advice  of  Malgaigne,2  and  I 
feel  sure  that  it  will  be  found  the  most  satisfactory.  The  patient  having  been 
prepared  for  the  operation  in  the  way  described  when  speaking  of  the  circu- 
lar method,  the  surgeon  with  his  left  hand  grasps  and  slightly  raises  the 
tissues  of  which  the  flap  is  to  be  formed,  and  then,  keeping  (as  advised  by 
Lisfranc)3  his  right  elbow  close  to  his  body,  introduces  the  long  pointed  knife 
at  the  side  of  the  limb  which  is  nearest  to  himself;  then  pusning  it  around 
and  across  the  bone  with  a  firm  but  gentle  movement,  and  somewhat  elevating 
the  handle  of  the  instrument  after  the  point  has  passed  the  hone,  he  completes 
the  transfixion  of  the  limb  by  bringing  the  knife  out  at  a  point  diametrically 
opposite  to  that  at  which  it  entered.  Keeping  the  blade  now  in  a  plane  cor- 
responding to  the  long  axis  of© the  limb,  he  forms  his  first  flap  by  cutting 
with  a  rapid  sawing  motion,  at  first  in  a  longitudinal  direction,  and  then 

obliquely  towards  the  surface.     The  flap  thus  made,  which  should  have  a 
o 

i  Op.  oil.,  p.  637.  2  Op.  cit.,  p.  295. 

3  Precis  de  Medecine  operatoire,  tome  i.  p.  737.     Paris.  1845. 


586 


AMPUTATIONS. 


length  of  at  least  half  the  diameter  of  the  limb,  is  then  turned  back  and 
entrusted  to  an  assistant,  while  the  surgeon  re-enters  his  knife  at  the  point  of 
original  puncture  (this  time  passing  on  the  other  side  of  the  bone),  brings  it 
out  as  before,  and  cuts  the  second  flap,  which  in  shape  and  size  should  be  as 
closely  symmetrical  as  possible  to  that  first  formed.  (Fig.  150.)  The  retractor 
is  next  adjusted;  any  remaining  fibres  divided  by  a  few  touches  of  the  knife; 
and  the  bone  sawn  as  in  the  circular  operation. 

Fig.  150. 


Amputation  of  forearm  by  double-flap  method. 

If  the  flaps  are  made  antero-posteriorly,  the  anterior  flap  is  usually  formed 
first ;  if  lateral  flaps  are  preferred,  the  outer  should  be  made  before  the  inner. 
The  general  rule  is  that  that  flap  should  be  last  cut  which  contains  the  prin- 
cipal artery. 

(3)  Sedillofs  method,  which  that  author  describes  as  a  "  mixed  procedure,"1 
differs  from  Vermale's,  in  that  the  surgeon,  instead  of  making  his  knife 
"  hug"  the  bone,  keeps  the  instrument  away  from  it  in  transfixing  the  limb, 
so  as  to  include  but  a  small  portion  of  muscular  tissue  in  each  flap;  the 
remaining  muscles,  together  with  the  great  vessels,  are  then  divided  by  a  cir- 
cular incision,  and  the  rest  of  the  amputation  completed  as  in  the  ordinary 
circular  method.  The  flaps  are  somewhat  shorter,  as  well  as  thinner,  than 
those  of  Vermale's  operation,  which  is  certainly  an  advantage  if  the  limb  be 
a  very  large  one.  I  have,  in  amputating  the  thigh,  sometimes  varied  Sedil- 
lofs procedure  by  cutting  superficial  flaps  from  without  inwards,  as  in  Lan- 
genbeck's  method,  and  then  completing  the  operation  by  a  circular  sweep  of 
the  knife,  in  the  ordinary  way.  The  stump  which  results  from  Sedillofs 
plan  of  operating,  closely  resembles  that  obtained  by  the  modified  circidar 
method,  over  which  it  does  not  appear  to  me  to  present  any  marked  supe- 
riority. 

Some  surgeons,  having  regard  to  the  gradual  atrophy  of  muscular  tissue 
which  always  occurs  in  a  stump,  attempt  to  save,  as  they  think,  time  and 
trouble,  by  making  their  flaps  from  skin  only;  but  not  only  is  there  consid- 
erable risk  of  the  Baps  sloughing,  under  these  circumstances,  hut  the  stump 
thus  obtained  is  less  serviceable  than  when  the  flaps  contain  muscle  also;  for 

1  Op.  cit.,  tome  i.  p.  331. 


OPERATIVE    METHODS    EMPLOYED    IN    AMPUTATION. 


587 


although  it  is  a  fact  that  the  true  muscular  substance  gradually  disappears  IV'  mi 
a  stump,  the  fibrous  sheaths  of  the  muscles  remain,  and,  becoming  condensed 
into  a  thick  and  resisting  mass,  form  a  useful  pad  for  protecting  the  Bawn 
extremity  of  the  bone. 

(4)  Langenbeck's  method,  which  has  already  been  incidentally  mentioned, 
consists  in  cutting  double  flaps  from  without  inwards.  This  plan  presents 
the  advantage  of  enabling  the  surgeon  to  shape  his  tlaps  more  accurately,  and 
to  better  insure  their  symmetry,  than  when  they  are  formed  by  transfixion. 
In  making  antero-posterior  tlaps  by  this  method,  the  posterior  flap,  contrary 
to  the  rule  before  given,  should  be  cut  first;  the  reason  for  this  is  that  if  the 
hinder  flap  were  left  to  be  formed  last,  the  line  of  incision  would  be  obscured 
by  the  blood  flowing  from  the  anterior  portion  of  the  wound. 

Langenbeck's  method  may  sometimes  be  advantageously  combined  with 
Vermale's,  one  flap  being  cut  from  within  outwards,  and  the  other  by  trans- 
fixion ;  in  some  localities,  as  the  leg,  this  is  the  plan  ordinarily  adopted,  the 
subcutaneous  position  of  the  tibia  rendering  it  very  difficult  to  cut  an  ante- 
rior flap  here  except  in  this  way.  This  combination-flap  method  is  also  very 
well  adapted  for  amputations  of  the  thigh  just  above  the  knee.  Another 
combination  of  these  two  methods  was  practised  by  Dupuytren  and  Larrey, 
who  cut  through  the  skin  from  without  inwards,  and  then  completed  their 
flaps  by  transfixion.1 

(5)  Teak's  Method,  or  Amputation  hy  a  Long  and  a  Short  Rectangular  Flap. — 
This  mode  of  operating,  which  unquestionably  affords  a  most  admirable 
stump,  was  first  practised  by  its  inventor,  the  late  Mr.  Teale,  of  Leeds,  in 
June,  1855.2     There  are  two  flaps  cut  from  without  inwards,  as  in  Langen- 


Fkr.  151. 


Amputation  of  forearm  by  Teale's  method. 


beck's  method,  but  with  the  peculiarity  that  they  are  rectangular,  and  that 
while  they  are  equally  wide,  one  is  just  four  times  as  long  as  the  other  |  Fig. 
151).     The  long  flap  is  taken  from  the  side  of  the  limb  on  which  there  is 


1  Lisfranc,  op.  cit.,  tome  i.  p.  733. 

2  On   Amputation  by  a  Long  and  a  Short  Rectangular  Flap. 
F.R.C.S.,  etc.,  page  13.     London,  1858. 


By  Thomas  P.  Teale,  F.L.S., 


055  AMPUTATIONS. 

least  muscular  tissue,  and  which  does  not  contain  the  principal  vessels  ;  both 
flaps  include  all  the  structures  down  to  the  bone.  The  surgeon  begins  by 
ascertaining,  with  a  piece  of  string  or  tape-measure,  the  circumference  of  the 
limb  at  the  point  at  which  it  is  to  be  removed  ;  half  of  this  circumference  - 
gives  the  dimensions  in  each  direction  of  the  long  flap,  which  must  represent 
a  perfect  square.  This  flap  having  been  marked  out  upon  the  limb  with  ink  or 
crayon,  the  dimensions  of  the  short  flap  are  similarly  indicated,  its  width  being 
likewise  half  the  circumference  of  the  limb,  but  its  length  only  one-eighth,  or 
one-fourth  the  length  of  the  long  flap.  It  is  very  important  that  the  flaps  should 
be  accurately  marked  out  upon  the  limb  before  beginning  the  operation,  as- 
otherwise,  when  taken  from  a  conical  limb,  the  long  flap  will  almost  certainly 
be  cut  narrower  at  its  extremity  than  at  its  base.  The  long  flap  is  cut  first, 
with  a  strong,  short  knife ;  turned  up,  and  given  in  charge  to  an  assistant ;  the 
short  flap  being  made,  the  retractor  is  applied,  and  the  rest  of  the  operation 
completed  as  in  the  circular  method.  In  closing  a  "  Teale  stump"  with  sutures, 
the  ends  of  the  flaps  must  be  first  brought  together,  and  the  lateral  wounds 
sewed  up  subsequently.     (Fig.  152.) 

Fig.  152. 


Stump  resulting  from  amputation  by  Teale's  method. 

The  advantage  of  this  mode  of  amputating  is  that  it  furnishes  a  firm 
cushion  of  soft  tissues  to  cover  the  end  of  the  bone,  and  that  it  allows  the 
cicatrix  to  be  entirely  withdrawn  from  pressure  in  the  adjustment  of  an  arti- 
ficial limb  ;  its  disadvantage  is  that,  when  the  limb  is  a  large  one,  the  peculiar 
form  of  the  flaps  requires  the  bone  to  be  sawn  at  a  much  higher  point  than 
would  otherwise  be  requisite,  and  thus  not  only  gives  a  very  short  stump, 
but,  at  least  in  the  case  of  the  thigh,  considerably  enhances  the  danger  of 
the  operation.  Tims,  in  a  case  of  injury,  should  the  laceration  of  the  soft 
parts  extend  as  high  as  the  patella,  and  the  thigh  be  six  inches  in  diameter 
— not  by  an}'  means  an  excessive  measurement — the  long  flap  would  have  to 
be  nine  inches  square  (half  the  circumference),  and  the  bone,  instead  of  being 
divided  in  its  lower  third,  as  it  would  be  in  the  circular  or  the  ordinary 
double-flap  operation,  would  be  sawn  above  its  middle,  and  the  risk  to  the 
patient  thus  materially  increased. 

In  order  to  obviate  this  disadvantage  of  Teale's  method,  the  next  plan  to 
be  described  was  suggested  about  twenty  years  ago  by  Prof.  Lister,  then  of 
(  Uasgow,  but  now  of  King's  College,  London. 

(0)  Lister's  Method. — This  mode  of  amputating  was  originally  recom- 
mended by  its  distinguished  author  for  operations  in  the  thigh  and  leg  only, 
but  it  is  equally  applicable,  as  I  have  found  by  experience,  in  other  situations 
also.  Lister's  operation  niav  be  described  as  something  midway  between  that 
of  Teale  and  the  old  operation  of  Ravaton.     In  the  latter,  as  will  be  remem- 


OPERATIVE    METHODS    EMPLOYED    IN    AMPUTATION.  589 

bered,  the  flaps  were  rectangular,  and  of  equal  length  ;  in  Teale's  operation, 
they  are  likewise  rectangular,  but  the  outer  or  anterior  flap  is  four  times  aa 
long  as  the  other.  Prof.  Lister's  suggestion  is  that  the  flaps  shall  be  so  pro- 
portioned that  the  line  of  cicatrix  shall  come  just  beyond  the  edge  of  the 
bone,  while  this  can  be  left  considerably  longer  than  in  the  Teale  operation  ; 
for  the  thigh  and  leg,  he  directs  that  the  principal  flap  shall  have  a  length  of 
one-third  of  the  limb's  circumference,  and  that  the  length  of  the  smaller  flap 
shall  be  one-half  that  of  the  larger.  He  also  rounds  oft',  somewhat,  the  angles 
of  the  flaps,  and  makes  the  posterior  flap  of  skin  and  fascia  only.  I  have 
employed  this  form  of  amputation,  or  at  least  one  embracing  the  same  prin- 
ciples, in  the  upper  extremity,  and  with  excellent  results;  I  have  preferred, 
however,  to  keep  the  rectangular  form  of  the  flaps,  as  in  Teale 's  method,  and 
to  make  both  flaps  include  muscle  as  well  as  skin  and  fascia. 

Relative  Advantages  of  Different  Modes  of  Amputating. — In  the 
writings  of  the  older  surgeons  may  be  found  frequent  controversial  disquisi- 
tions on  the  alleged  superiority  of  one  or  another  mode  of  amputating  over 
all  other  plans,  and  it  is  within  my  own  recollection  that  some  distinguished 
operators  never  resorted  to  any  but  the  circular  incision,  while  others  as 
invariably  employed  some  variety  of  the  flap  method.  For  my  own  part,  I 
have  long  been  convinced,  both  by  individual  experience  and  by  operations 
which  I  have  seen  done  by  others,  that  the  particular  form  of  operation 
chosen,  is  of  comparatively  slight  importance:  provided  that  sufficient  cover- 
ing be  secured  for  the  bone,  it  matters  little  whether  that  covering  be  in 
the  form  of  a  circular  or  oval  cutf,  or  of  one  or  two  flaps,  or  whether 
the  corners  of  the  latter  be  angular  or  rounded.  I  shall  not  dispute,  with 
Liston,1  the  judgment  of  those  "philosophers  of  the  modern  Athens/'  who 
provoked  his  wrath  and  sarcasm  by  asserting  that  the  wound-area  of  a  cir- 
cular amputation  was  less  than  that  exposed  by  the  flap  operation  ;  nor  shall 
I  deny  that  the  arteries  are  apt  to  be  cut  obliquely  in  removing  a  limb  by 
the  latter  method ;  but,  though  I  confess  to  a  growing  fondness  for  the  old- 
fashioned  circular  incision,  and  find  myself  employing  it  more  commonly 
year  by  year,  when  the  special  circumstances  of  the  case  do  not  render  it 
less  desirable  than  some  other  procedure,  yet  I  cannot  conscientiously  say  that 
I  think  that  the  form  of  operation  adopted  exercises  any  marked  influence 
upon  the  result.  The  judgment  manifested  in  determining  whether  an  ampu- 
tation shall  or  shall  not  be  performed,  and  the  care  taken  in  the  after-treat- 
ment of  the  patient,  are  of  much  more  importance. 

At  the  same  time,  the  operation  which  may  be  best  adapted  to  one  parti- 
cular case,  may  be  less  well  suited  to  another;  and  the  surgeon  should  be 
sufficiently  familiar  with  all  the  methods  which  have  been  described,  to 
enable  him  to  choose  that  which  is  most  appropriate  in  the  special  circum- 
stances with  which  he  is  concerned.  If  I  were  to  give  any  general  rule.  I 
should  say  that  for  the  forearm,  the  circular  operation  was  the  best,  and  for 
the  upper  arm,  either  that  or  the  modified  circular;  the  latter  operation  I 
should  prefer  for  the  upper  part  of  the  thigh,  and  either  it  or  the  simple  circular 
for  the  lower  part  of  the  leg ;  for  the  lower  part  of  the  thigh,  and  for  the  ?//>/«  r 
part  of  the  leg,  I  should  recommend  the  flap  method — antero-posterior  flaps 
being  chosen  in  the  former,  and  an  external  flap  in  the  latter  situation.  The 
oval  and  elliptical  operations  are  particular! y  well  fitted  for  amputations 
at  the  joints,  while  the  single-flap  and  Teale's  or  Lister's  methods  will  serve 
a  useful  purpose  where  the  disease  or  injury  involves  less  of  the  tissues  on 
one  side  of  the  limb  than  on  the  other. 

1  Op.  cit.,  p.  642. 


590  AMPUTATIONS. 


Simultaneous  or  Synchronous  Amputations. 

It  not  unfrequently  happens  that,  as  the  result  of  injury  or  disease,  two 
or  even  more  limbs  in  the  same  patient  may  be  so  hopelessly  disorganized  as 
to  call  for  amputation.  Should  both  or  all  the  operations  be  done  at  once? 
or  should  the  patient  be  allowed  to  recover  from  the  effects  of  one  operation 
before  another  is  attempted?  That  French  surgeon,  Faure,  against  whom 
Velpeau1  directed  the  shafts  of  his  sarcasm,  and  who  proposed  that  the  sur- 
geon should  do  a  single  amputation  by  slow  and  easy  stages,  stopping  to  rest 
for  four  or  five  days  after  each,  and  thus  prolonging  the  whole  duration  of  the 
operation  for  a  fortnight  or  so,  would  no  doubt  have  advised  without  hesita- 
tion that  but  one  operation  should  be  done  at  a  time ;  and  in  certain  cases 
this  advice  would  be  judicious.  Thus,  in  a  patient  suffering  from  chronic 
bone-and-joint  disease,  scrofulous  or  syphilitic,  it  may  be  good  practice  to 
remove  the  part  which  causes  most  suffering,  and  postpone  further  operative 
interference  for  months,  or  even  years ;  for  even  if  the  other  affected  parts 
should  not  recover  themselves  (which  is  always  possible),  the  patient's  life 
would  be  less  endangered  by  successive  operations  performed  at  considerable 
intervals,  than  by  two  or  more  amputations  performed  at  the  same  time. 
Even  in  cases  of  gangrene  following  frost-bite — a  not  unfrequent  cause  of 
double  amputation — it  may  be  proper  to  remove  one  of  the  affected  members 
as  soon  as  the  line  of  separation  is  established,  and  to  postpone  the  second 
operation  until  the  patient  has  recovered  from  the  first. 

But  in  most  cases  of  double  or  multiple  injury,  requiring  amputation,  at 
least  in  civil  life,  the  only  hope  of  the  patient  lies  in  prompt  removal  of  all 
the  crushed  parts.  In  military  surgery,  it  is  somewhat  different;  gunshot 
fractures  of  limbs  are  often  attended  with  less  immediate  danger  than  simi- 
lar compound  fractures  resulting  from  other  causes,  in  which  the  soft  parts 
are  more  involved ;  and  hence  the  army  surgeon  may  be  justified  in  amputa- 
ting only  the  worst-hurt  limb,  at  first,  and  in  treating  the  other  for  a  time  ex- 
pectantly, even  though  he  may  feel  sure  that  a  secondary  operation  will  event- 
ually be  required.  The  prospect  of  recovery  under  these  circumstances  is  of 
course  greater  than  when  several  limbs  have  to  be  removed  simultaneously, 
and  hence  most  of  the  successful  multiple  amputations  recorded  have 
occurred  in  military  practice. 

Quadruple  amputations,  or  amputations  of  both  upper  and  both  lower  extremities, 
have  proved  successful  in  the  hands  of  Dr.  Alfred  Muller,  Acting  Assistant  Surgeon, 
U.  S.  A.,  Dr.  Begg,  of  Dundee,  and  M.  Champenois,  a  surgeon  of  the  French  army. 
Other  cases  are  referred  to  by  Morand,  by  Prof.  Longmore,  and  by  Soutliam  of  Man- 
chester, and  two  are  mentioned  by  H.  Larrey,  one  patient  having  been  seen  at  the 
"  Invalided,"  i"  Paris,  and  the  other  in  Algiers.  In  none  of  the  eight  cases  do  all  the 
operations  appear  to  have  been  synchronous,  though  in  Champenois's  case  three  limbs 
were  removed  on  one  day,  and  the  fourth  two  days  afterwards.  Dr.  Koehler,  of 
Schuylkill  Haven,  Pennsylvania,  has  recorded  a  successful  synchronous,  triple  amputa- 
tion (both  legs  and  one  arm)  in  a  boy  of  thirteen,  and  similar  cases  are  attributed  by 
Prof.  Agnew2  to  the  late  Dr.  Stone,  of  New  Orleans,  and  to  an  unnamed  surgeon  of 
York,  Pennsylvania.  Another  successful  triple  amputation  (not  synchronous)  has 
been  reported  by  Leseleuc,  of  Brest.  J.  Ritter  has  reported  two  cases  of  triple  ampu- 
tation for  gangrene  following  frost-bite,  and  other  triple  amputations  have  been  recorded 
by  Marten,  Bruberger,  and  Field,  of  Texas. 

Double  synchronous  amputations  are  not  very  rare,  but  (except  when  the 
feel   "i-  hands  only  are  involved)  are,  unfortunately,  not  usually  successful; 

1  Op  cit.,  tome  ii.  p.  3.06.  2  Principles  and  Practice  of  Surgery,  vol.  ii.  p.  374. 


pi.  hi. 


tisF&M 


£ijuclW^ucm>CtmfmUtUmi  of  tcf(   tVg  euui  ucjlU  Hip  jmul 

c1\«h    «    paUeul  iu  {fie  C?6x*{vil«*£  of  Hie  %mv*,.u1.j  of  !'4\:im.Hjfvmtia . 


SIMULTANEOUS   OR   SYNCHRONOUS   AMPUTATIONS.  591 

eleven  such  cases,  under  my  own  care,  have  given  seven  deaths  and  but  four 
recoveries.  In  one  of  these,  the  right  thigh  and  left  leg  were  simultaneously 
removed  for  railway  injury  by  my  friend  and  assistant,  Dr.  II.  R.  Wharton; 
the  patient,  who  was  an  adult,  recovered  without  a  single  unfavorable  symp- 
tom. Another  case,  which  has  furnished  the  subject  of  the  accompanying 
plate  (Plate  III.),  is  worthy  of  being  narrated  in  more  detail : — 

George ,  aged  fifteen,  was  admitted  to  my  ward  in  the  University  Hospital, 

while  I  happened  to  be  in  the  building,  on  the  afternoon  of  June  4,  1879,  having  a 
short  time  before  fallen  from  and  been  run  over  by  a  train  on  the  Philadelphia,  Wil- 
mington and  Baltimore  Railroad,  which  passes  not  far  from  the  hospital.  The  ri^ht 
limb  had  been  absolutely  torn  off  above  the  knee,  the  femur  being  badly  shattered  and 
the  skin  and  fascia  completely  separated  as  far  up  as  the  groin.  The  left  leg  was  also 
crushed  in  its  lower  third,  both  bones  broken  obliquely,  and  the  soft  parts  greatly  lace- 
rated. Slow  but  steady  bleeding  was  going  on  from  the  left  leg,  while  on  the  right  side  it 
was  only  restrained  by  digital  compression  of  the  iliac  artery,  which  had  been  promptly 
instituted  by  Dr.  Palmer,  the  house  surgeon,  with  the  aid  of  two  or  three  senior  students 
who  were  in  the  ward  when  the  patient  was  brought  in.  Notwithstanding  the  lad's 
apparently  desperate  injuries,  I  found  him  in  a  condition  which,  while  far  from  pro- 
mising, did  not  absolutely  forbid  an  operation,  and — surgical  instinct  forbidding  non- 
interference while  hemorrhage  was  actually  present — I  determined,  with  the  skilful 
assistance  of  Dr.  R.  A.  Cleemann,  who  was  visiting  the  hospital  with  me,  to  amputate. 
Bleeding  being  temporarily  controlled  by  a  pair  of  Esmareh's  tubes,  rolled  one  around 
the  left  leg  and  the  other  around  the  stump  of  the  right  thigh,  the  patient  was  carefully 
etherized,  and  then,  having  adjusted  a  Lister's  aortic  compressor  so  as  to  command  both 
iliac  arteries,  I  amputated  at  the  right  hip-joint,  cutting  antero-posterior  flaps  from 
without  inwards,  as  in  Guthrie's  method,  making  the  posterior  flap  first,  and  being 
obliged  to  include,  in  the  anterior,  a  good  deal  of  the  skin  which  had  been  torn  up  and 
separated  in  the  original  injury.  The  vessels  having  been  secured,  a  fold  of  oiled  lint 
was  temporarily  placed  between  the  flaps,  and  then,  finding  that  the  patient's  pulse  per- 
mitted it,  I  turned  to  the  left  leg,  which  I  immediately  amputated  at  its  middle  by  the 
modified  circular  method.  Both  the  elastic  tube  and  the  tourniquet  were  used  on  this 
limb,  in  the  way  described  on  page  570.  All  bleeding  vessels  having  been  tied,  both 
wounds  were  closed  with  silver  wire  sutures,  and  simply  dressed  with  lint  soaked  in 
olive  oil  (not  carbolized),  covered  with  oiled  silk,  and  kept  in  place  with  adhesive  strips 
and  roller  bandages. 

During  the  operations,  I  had  an  assistant  give  repeated  hypodermic  injections  of 
ether — a  syringe-full  at  a  time — and  I  find  by  my  notes  that  it  was  estimated  that  a 
fluidounce  of  ether  was  consumed  in  this  way.  After  the  patient  was  put  to  bed — for 
I  had  operated  while  he  lay  on  the  stretcher  on  which  he  had  been  carried  to  the  hos- 
pital— the  ether  injections  were  continued  until  he  had  rallied  enough  to  be  able  to 
swallow,  and  then  five  grains  of  carbonate  of  ammonium  were  given  by  the  mouth 
every  half  hour  until  thorough  reaction  had  occurred.  This  was  further  promoted  by 
the  use  of  external  heat,  and,  though  the  patient  seemed  almost  moribund  when  the 
operations  were  completed,  his  condition  rapidly  improved,  and  his  convalescence  from 
that  time  proceeded  without  an  unfavorable  symptom.  An  alcoholic  dressing  was  sub- 
stituted for  the  oiled  lint  after  the  first  forty-eight  hours;  the  last  ligature  came  from 
the  leg-stump  on  the  eighth,  and  the  femoral  ligature  from  the  hip-wound  on  the  twelfth 
day.  The  patient  was  kept  in  hospital  until  January,  1880,  his  wounds  having  then 
been  entirely  healed  for  about  four  months. 

As  far  as  my  reading  goes — and  I  am  confirmed  by  the  opinion  of  un- 
valued friend  the  late  Dr.  G.  A.  Otis,  Surgeon  U.  S.  Army,  whose  familiarity 
with  the  literature  of  hip-joint  amputation  was  probably  greater  than  that  id' 
any  man  now  living — this  is  the  only  case  recorded  in  which  a  successful 
primary  amputation  at  the  hip-joint  has  been  performed  synchronously  with 
another  major  amputation.  Among  my  unsuccessful  double  amputations,  I 
count  two  cases  in  which  the  right  arm  was  removed  at  the  shoulder-joint,  in 
one,  in  connection  with  amputation  in  the  lower  third  of  the  left  leg,  and  in 


592 


AMPUTATIONS. 


the  other  in  connection  with  amputation  of  the  left  upper  arm  at  its  middle. 
Besides  cases  of  double  major  amputation,  I  have  twice  had  occasion  to  remove 
portions  of  both  feet  (in  one  instance  the  whole  foot,  on  one  side)  for  gangrene 
resulting  from  frost-bite;  in  both  of  these  cases  the  patients  recovered.  The 
particulars  of  all  the  cases  referred  to  are  compendiously  shown  in  the  an- 
nexed Table: — 


Table  Showing  the  Particulars  of  Eleven  Cases  of  Double 
Synchronous  Amputation. 


No. 

Sex  and 
Age. 

Nature  of  Lesion. 

Operation. 

Result. 

Date. 

Remarks. 

1 

Male 

Crush    of   both 

Amputation  of  right  leg  at 

Died  in 

1865 

Episcopal 

aged  5 

lower  extremi- 

middle (circular)  and  left 

3  hours 

Hospital. 

years 

ties 

thigh  at  upper  third  (modi- 
fied circular) 

2 

Male 

Crush  of    both 

Amputation  of  both  legs  at 

Died  in 

1866 

do. 

aged  35 

lower  extremi- 

knee (flap) 

8  hours 

years 

ties 

3 

Male 

Crush   of   both 

Amputation  of  right  arm  at 

Died  in 

1867 

do. 

adult 

upper  extremi- 
ties 

middle  (circular)  and  left 
arm  at  upper  third  (oval) 

3  days 

Injuries  of  head 
also. 

4 

Female 

Frost  -  bite    of 

Amputation    of    both    feet 

Recovered 

1871 

Episcopal 

adult 

both  feet 

through    metatarsus   (an- 
teroposterior flap 

Hospital. 

5 

Male 

aged  49 

years 

Frost  -  bite     of 
both  feet 

Amputation    of    right    foot 
through  metatarsus  (flap) 
and    left    foot     at    ankle 
(Syme) 

Recovered 

1876 

do. 

6 

Male 

Avulsion  of  right 

Amputation    at    right  hip- 

Recovered 

1879 

University 

aged  15 

and    crush    of 

joint  (flap)  and  of  left  leg 

Hospital. 

years 

left  lower  ex- 
tremity 

at  middle  (modified  circu- 
lar) 

7 

Male 

Crush  of  right 

Amputation  of  right  leg  at 

Died  in 

1879 

do. 

adult 

leg    and     left 
foot 

middle  (modified  circular) 
and    left    foot    at     ankle 
(Syme) 

9  hours 

8 

Male 

Crush   of   both 

Amputation  at  right  knee 

Died  in 

1880 

do. 

adult 

lower  extremi- 
ties 

(nap)    and  of   left  leg  at 
lower  third  (modified  cir- 
cular) 

4  hours 

Injuries  of  head 
also. 

9 

Male 

Crush  of  right 

Amputation  at  right  shoul- 

Died in 

1880 

Episcopal 

aged  32 

arm   and    left 

der-joint  (Larrey)  and  of 

4  days 

Hospital. 

years 

foot 

left    leg    at    lower    third 
(circular) 

Injuries  of  head 
also.  Slight  re- 
actionary hem- 
orrhage. 

10 

Male 

Avulsion  of  right 

Amputation  at  right  shoul- 

Died in 

1880 

University 

aged  25 

and    crush    of 

der-joint  (Larrey)  and  of 

11  hours 

Hospital. 

years 

left  upper  ex- 
tremity 

left  arm  at  middle  (modi- 
fied circular) 

Injuries  of  head 
also. 

11 

Male 

Crush    of   both 

Amputation   at   right   knee 

Recovered 

1880 

University 

adult 

lower  extremi- 
ties 

(flap)  and  of  left   leg  at 
upper  third  (flap) 

Hospital. 
Operation  by  Dr. 
H.  R.  Wharton. 

It  is,  I  think,  better  in  these  synchronous  amputations,  provided  that  the 
circulation  is  thoroughly  controlled  with  tourniquets,  to  complete  both  ope- 
rations, as  far  as  the  knife  is  required,  before  pausing  to  ligate  the  divided 
vessels;  and,  under  any  circumstances,  both  limbs  should  be  removed  before 
either  stump  is  dressed.  Before  the  days  of  anesthesia,  it  was  sometimes 
recommended  that  both  operations  should  be  done  actually  at  the  same 
moment,  by  separate  surgeons,  it  being  thought  that  if  the  patient's  attention 


DRESSING   THE   STUMP.  593 

were  divided  between  two  focuses  of  suffering,  he  would  feel  less  pain  from 
either,  than  if  the  operations  were  performed  consecutively  ;  whatever  may 
have  been  the  advantages  of  such  a  procedure  in  former  times,  there  is  no 
occasion  for  such  a  course  now,  and  the  operations  will  be  certainly  more  apt 
to  be  done  well  if  only  one  is  done  at  a  time. 


Dressing  the  Stump. 

"We  have  carried  the  description  of  an  amputation  as  far  as  the  closing  of 
the  wound  with  sutures ;  this  is,  at  the  present  day,  almost  universally  done 
before  the  patient  recovers  from  the  influence  of  the  anaesthetic  that  has  been 
administered,  and,  provided  that  ample  drainage  is  secured  either  by  means 
of  the  ligature  ends  or  by  the  use  of  a  tube,  the  plan  is  a  good  one,  as  avoid- 
ing the  infliction  of  pain  at  the  time  when  the  patient  is  least  able  to  bear  it. 
There  was  merit,  however,  in  the  custom  of  our  ancestors  of  allowing  a 
wound  to  "  glaze,"  as  they  called  it — that  is,  to  become  smooth  and  sticky 
from  the  presence  of  lymph — before  it  was  closed ;  and  if  there  be  any  reason 
to  fear  consecutive  hemorrhage,  it  is  a  good  plan  to  simply  introduce  the 
stitches,  without  tightening  them,  and  to  lay  a  piece  of  oiled  lint  in  the 
wound  (as  advised  by  Mr.  Butcher,  of  Dublin),  so  as  to  prevent  prema- 
ture adhesion.  This  may  readily  be  removed,  and  the  wound  finally  closed, 
after  reaction  has  occurred,  without  giving  the  patient  any  additional  pain. 
If  the  stump  be  a  light  one  (as  in  the  forearm),  it  is  not  desirable  to  employ 
any  means  of  approximation  other  than  the  sutures,  though  a  short  strip  of 
plaster  may  be  laid  transversely  over  the  ends  of  the  ligatures,  to  keep  them 
from  being  caught  in  the  dressings  and  perhaps  pulled  upon  before  they 
have  become  loose.  If,  however,  there  be  heavy  flaps,  it  will'  be  well  to 
give  additional  support  by  applying  a  few  narrow  adhesive  strips  between 
the  sutures,  and  in  a  longitudinal  direction.  Under  no  circumstances  should 
a  transverse  strip  be  carried  completely  around  the  stump ;  any  such  source  of 
eircular  compression  will  probably  cause  oedema,  and  may  even  lead  to  gan- 
grene, or  possibly,  as  in  a  case  recorded  by  Sir  James  Paget,1  to  death. 
Another  mistake,  which  should  be  most  scrupulously  avoided,  is  the  closing 
of  the  wound  so  tightly  as  to  hermetically  seal  it;  there  is  inevitably  a  con- 
siderable flow  of  sero-sanguineous  fluid  after  an  amputation,  and  if  this  be 
confined  within  the  wound,  instead  of  being  allowed  to  escape,  painful  dis- 
tension results,  and  interference  with  primary  union,  not  to  speak  of  the 
danger  of  septicaemia  from  decomposition. 

Various  modes  of  dressing  stumps  have  found  favor  wdth  modern  sur- 
geons; with  perhaps  one  or  two  exceptions,  all  are  better  than  the  old  plan, 
which  still  prevailed  within  my  recollection,  of  applying  a  large  piece  of  lint 
smeared  with  some  unctuous  substance  (often  cut  in  the  form  of  a  Maltese 
cross,  and  folded  closely  around  the  stump),  then  a  thick  nest  of  charpie,  and 
finally  a  rather  tight  bandage.  I  shall  describe  briefly  several  of  the  stump 
dressings  which  have  obtained  most  favor  in  recent  years,  concluding  with 
that  which,  in  common  with  many  other  surgeons,  I  am  myself  in  the  habit 
of  employing,  and  which  I  would  venture  to  designate  as  the  "simple  dressing 
for  amputations." 

Cold-avater  Dressing. — Introduced  into  British  surgery  by  Liston,  this  is 
still  a  favorite  mode  of  dressing  amputation  wounds  in  military  practice,  and 

1  Clinical  Lectures  and  Essays,  p.  63.     Second  Edition.     London,.  1819* 
VOL.  I. — 38 


594 


AMPUTATIONS. 


Irrigating    apparatus    for 
cold-water  dressing. 


Fig.  153.  was  very  extensively  employed  during  our  late  war. 

The  stump  is  simply  laid  upon  a  pillow  protected  with 
a  piece  of  oil-cloth  and  a  towel  or  fold  of  linen,  and 
then  another  piece  of  linen,  or  lint,  wrung  out  of  cold 
water,  laid  over  it,  and  constantly  moistened  by  an 
attendant,  or,  if  practicable,  by  the  adjustment  of  an 
irrigating  apparatus  (Fig.  153).  There  is  no  better  or 
more  soothing  application  to  a  recent  stump,  in  hot 
weather,  than  this  simple  cold-water  dressing ;  it,  how- 
ever, requires  constant  supervision  on  the  part  of  the 
attendant, and, unless  care  be  taken  to  arrange  the  pillow 
and  oil-cloth  so  that  the  drip  may  fall  into  a  bucket  or 
basin  suitably  placed,  the  water  will  flow  backwards 
into  the  bed  and  keep  the  patient  constantly  wet,  thus 
exposing  him  to  great  discomfort,  as  well  as  to  the  risk 
of  becoming  chilled,  and,  perhaps,  falling  a  victim  to 
pneumonia  or  other  internal  inflammation.  Hence  while 
recognizing  the  advantages  of  this  mode  of  dressing  in 
army  practice,  or  in  cases  of  emergency,  I  do  not  recom- 
mend its  general  employment. 

In  connection  with  the  cold-water  dressing  of  ampu- 
tation wounds,  I  may  briefly  mention  the  continuous  bath 
of  Langenbeck  and  Lefort,  recently  revived  by  Prof.  Hamilton,  of  New  York, 
and,  with  the  modification  of  carbolizing  the  bath,  so  as  to  make  it  antisep- 
tic, by  Prof.  Verneuil,  of  Paris. 

Air  Dressing. — I  would  venture  to  propose  this  name  for  the  plan  of  treat- 
ing amputation  wounds  recommended  by  Mr.  Teale,  of  Leeds,  and  Prof. 
Humphry,  of  Cambridge,  and  advocated  with  the  great  ability  and  eloquence 
which  characterized  all  his  writings,  by  the  late  Sir  J.  Y.  Simpson,  of  Edin- 
burgh. Mr.  Teale,  after  directing  that  the  wound  should  be  closed  with 
sutures,  says  : — 1 

"  After  the  patient  has  been  carried  to  bed,  the  stump  is  laid  on  a  pillow,  over  which 
a  large  sheet  of  gutta-percha  tissue  has  been  spread.  No  dressing  whatever  is  required 
in  the  early  part  of  the  treatment.  A  light  piece  of  linen  or  gauze  is  thrown  loosely 
over  the  stump  and  pillow,  and  these  are  protected  from  the  pressure  of  the  bedclothes 
by  a  wire-work  guard.  .  .  .  The  attendants  and  nurses  must  be  strictly  enjoined 
not  to  lift  the  stump  from  the  pillow  without  the  authority  of  the  surgeon.  As  there 
are  no  dressings  to  be  soiled,  and  therefore  to  require  removal,  the  stump  generally 
need  not  be  raised  from  the  pillow  for  many  days,  or  even  for  two  or  three  weeks. 
When  there  is  a  discharge  of  matter,  the  nurse  must  remove  it  frequently  by  a  soft 
sponge  from  the  subjacent  gutta-percha  without  lifting  the  stump." 

Prof.  Humphry,2  refering  to  the  well-known  fact  that  wounds  of  the  face 
not  unfrequently  heal  by  the  first  intention,  says : — 

"  This  is  due,  in  great  measure,  to  the  vital  qualities  of  these  parts,  and,  in  some 
degree,  also,  I  apprehend,  to  the  fact  that  they  are  usually  exposed  to  the  air,  their 
edges  being  held  in  contaol  merely  by  sutures.  For  some  years  we  have  adopted  this 
plan  after  amputations,  and  all,  or  nearly  all,  other  operations.  The  integuments  are 
united  by  sutures  placed  at  intervals  of  about  an  inch  ;  and  the  wound,  as  well  as  the 
adjacent  surf':i<'<\  is  left  quite  exposed  to  the  air  ;  no  plaster,  bandage,  or  dressing  of  any 
kind  being  placed  upon  it." 

1  Op.  cit.,  page  0. 

2  British  Medical  Journal,  October.,  1860,  p.  840,  quoted  by  Simpson,  Acupressure,  page  130. 
Edinburgh,  1864. 


DRESSING   THE   STUMP.  595 

And  Sir  J.  Y.  Simpson,  discoursing  on  "  The  General  Inutility  of  Dress- 
ings," says  :l — 

"  I  believe  .  .  .  that  after  the  sides  and  edges  of  a  wound  are  properly  approxi- 
mated and  adjusted  with  its  metallic  stitches,  the  best  dressing,  as  a  general  rule,  is 

nothing,  absolutely  nothing.  ...  I  have  found  that  occasional  streams  of  cold  air 
directed  upon  the  wound  or  its  vicinity  from  a  pair  of  bellows  prove  both  most  beneficial 
locally  in  keeping  down  morbid  heat  and  irritation,  and  are  most  grateful  to  the  feelings 
of  the  patient." 

Pneumatic  Occlusion  and  Pneumatic  Aspiration.  — In  contrast  to  the 
views  of  the  writers  just  quoted,  who  attributed  a  positively  curative  action 
to  the  contact  of  atmospheric  air,  we  may  next  consider  the  modes  of  dress- 
ing recommended  by  several  French  surgeons  who,  by  preventing  exposure 
of  amputation  wounds  to  air,  endeavor  to  place  them  in  a  condition  analogous 
to  that  of  subcutaneous  injuries.  As  pointed  out  by  II.  Larrey  in  the  dis- 
cussion before  the  French  Imperial  Academy  of  Medicine,  the  germ  of  these 
ideas  may  be  found  fairly  set  forth  in  the  Treatise  on  Wounds  of  Caesar 
Magatus,8  a  Franciscan  Monk  and  Professor  at  Ferrara,  who  lived  from  1579 
to  1647 ;  but  the  first  practical  application  of  the  method  in  modern  times, 
may  probably  be  attributed  to  Chassaignac,3  who,  in  connection  with  his  sys- 
tem of  drainage  tubes,  recommended  that  the  wound  should  be  closely  covered 
with  strips  of  plaster,  and  so  excluded  from  the  air. 

Pneumatic  Occlusion. — The  name  of  "Pneumatic  Occlusion"  was  given  by  M. 
Jules  Guerin  to  a  method  of  dressing  wounds  of  all  kinds,  including  those  made 
by  amputation,  which  he  described  before  the  Academic  deMSdetine,  in  Febru- 
ary, 1865.4  The  apparatus  required  for  this  mode  of  treatment  consists  of  (1) 
an  exhausted  metallic  receiver,  provided  with  gauge  and  stopcock  ;  (2)  a  series 
of  envelopes  or  sleeves  of  vulcanized  India-rubber,  of  various  forms  and 
dimensions,  ending  in  vulcanized  India-rubber  tubes,  which  are  firm  enough 
to  resist  atmospheric  pressure ;  and  (3)  a  series  of  very  fine  elastic  envelopes 
which  are  capable  of  adapting  themselves  to  the  inequalities  of  the  part  to 
which  they  are  applied,  and  which  are  permeable  to  the  atmosphere,  and 
are  placed  inside  of  the  others.  The  stump  is  first  surrounded  with  the  thin 
elastic  envelope,  and  then  placed  inside  of  the  India-rubber  sleeve,  the  neck 
of  which  is  made  to  clasp  the  limb  with  sufficient  closeness  to  prevent  its 
slipping;  the  exhausted  receiver  is  then  attached,  and,  the  stopcock  being 
turned,  the  air  and  gases  contained  in  the  sleeve  pass  into  the  receiver,  and 
the  former,  with  the  fine  enveloping  tissue,  yielding  to  atmospheric  pressure, 
mould  themselves  to  the  surface  of  the  stump,  which  they  hermetically 
seal. 

A  somewhat  similar  apparatus,  but  employed  with  a  different  purpose — 
that  of  keeping  the  stump  at  an  even  temperature — had  been  previously  sug- 
gested by  Jules  Guyot,  whose  mode  of  treatment  was  designated  as  the  In- 
cubation Method. 

Pneumatic  Aspiration  is  the  name  given  by  M.  Maisonneuve5  to  a  method 
of  dressing  stumps,  not  unlike  that  of  M.  Guerin,  which  has  just  been  de- 
scribed.    It  consists — 

1  Acupressure,  etc.,  page  116.     Edinburgh,  1864. 

2  Caesaris  Magati  Scandianensis  De  Rara  Medicatione  Vulnerum,  etc.     Venetiis,  1676. 

3  SSdillot,  op.  cit.,  tome  i.  p.  342. 

4  Bulletin  de  l'Academie  lmpe>iale  de  Medecine,  tome  xxxi.  p.  396. 

5  Practitioner,  vol.  i.  p.  1.     London,  1868. 


596  AMPUTATIONS. 

"  ...  in  submitting  the  stump  of  the  amputated  limb  to  continued  suction 
(vacuum),  so  as  to  draw  off  all  the  liquids  as  fast  as  they  are  formed,  and  to  convey 
them  away  before  they  have  had  time  to  putrefy.  This  is  how  the  process  is  carried 
out ;  after  having  stopped  the  hemorrhage  in  the  usual  way,  by  means  of  ligatures  to 
the  vessels,  I  clean  the  wound  with  the  greatest  care,  wash  it  with  alcohol,  and  wipe  it 
with  a  dry  cloth.  I  bring  the  edges  together  with  a  few  strips  of  diachylon,  but  with- 
out opposing  an  obstacle  to  the  flow  of  the  secreted  liquids.  I  then  apply  a  layer  of  lint 
soaked  in  antiseptic  liquids,  such  as  tincture  of  arnica,  solution  of  carbolic  acid,  or  other 
suitable  substance,  and  finally  I  fold  the  whole  in  a  few  bands  of  linen  soaked  in  the  same 
preparations.  It  is  only  after  this  preliminary  dressing  that  the  apparatus  for  exhausting 
the  air  is  applied.  The  apparatus  consists  (1)  of  an  extremity  of  India-rubber,  shaped 
like  a  lady's  muff,  and  intended  to  embrace  the  stump,  and  a  tube  of  the  same  sub- 
stance ;  (2)  of  a  vessel  of  four  or  five  litres  (3^  quarts  to  one  gallon)  capacity,  provided 
with  a  mouth-piece  pierced  with  two  holes;  and  (3)  of  an  exhausting  pump,  fitted  with 
a  flexible  tube.  The  stump  covered  with  its  bandage  is  first  placed  in  the  '  India- 
rubber  muff,'  whose  orifice  embraces  exactly  the  integuments  of  the  limb,  and  the  tube 
is  placed  in  connection  with  one  of  the  holes  in  the  mouth-piece  of  the  vessel.  To  the 
other  aperture  I  adapt  the  tube  from  the  exhausting  pump,  and  then  I  work  the  piston. 
In  a  short  time  the  air  of  the  vessel  is  in  great  part  drawn  off,  and  the  remainder  is 
rarefied.  The  liquids  of  the  dressing,  mixed  with  those  which  proceed  from  the  wound, 
follow  the  air,  and  flow  into  the  vessel.  The  '  India-rubber  muff",'  deprived  of  the  air 
it  had  contained,  applies  itself  closely  to  the  limb.  The  pressure  of  the  atmosphere 
exercises — through  the  intervention  of  the  India-rubber — a  considerable  compression 
of  the  stump,  and  thus  keeps  the  divided  surfaces  in  contact,  and,  combined  with  the 
continued  exhaustion  produced  by  the  rarefaction  of  the  air  in  the  vessel,  prevents  all 
accumulation  of  liquid,  and  thus  promotes  and  favors  rapid  cicatrization." 

Could  any  systems  of  dressing  be  more  unlike  than  those  which  we  have 
just  considered,  and  the  "  air-dressings"  of  Teale,  Humphry,  and  Simpson ; 
and  yet  the  advocate  of  each  mode  deplores  the  great  mortality  of  amputa- 
tions in  the  hands  of  other  surgeons,  and  confidently  puts  forward  his  own 
method  as  that  which  by  clinical  experience  he  has  proved  to  be  the  best. 

It  has  for  many  years  been  the  boast  of  modern  surgery  that  it  had  aban- 
doned the  old  doctrines  of  "digestion"  and  "  mundification"  of  amputation- 
wounds,  and  that  it  now  endeavored  to  promote  the  quick  healing  of  stumps 
by  primary  union.  And  yet  in  two  of  the  most  highly  lauded  methods  of 
dressing  employed  at  the  present  day,  no  attempt  is  made  to  close  the  wound 
for  days  after  the  operation ;  I  allude  to  the  perchloride  of  iron  dressing  of 
M.  Bourgade,  of  Clermont-Ferrand,  and  to  the  open  method  of  dressing  stumps 
employed  by  Prof.  J.  R.  Wood,  of  ISew  York. 

Perchloride  of  Iron  Dressing. — The  practice  of  cauterizing  an  amputa- 
tion-wound is  an  old  one,1  but  the  principle  upon  which  M.  Bourgade 
found-;  his  method,  first  brought  before  the  International  Medical  Congress  of 
Paris,  in  1868,  differs  from  that  upon  which  the  older  surgeons  acted.  Re- 
calling the  well-known  facts  that  recent  wouvds  are  more  prone  to  absorb  sep- 
tic materials,  whether  from  their  own  secretions  or  from  the  atmosphere, 
than  granulating  surfaces,  and  that  septic  poisoning  is  less  common  after  ope- 
rations performed  with  the  caustic  than  after  those  accomplished  by  the  use 
of  the  knife,  M.  Bourgade2  endeavors  to  render  the  latter  as  inoffensive  as 
the  former,  by  applying  f<>  the  whole  cut  surface  a  strong  solution  of  pcrchlo- 
ride  of  iron  (Pravaz's  solution,  sp.  gr.  30°  Baume).  Hemorrhage  having 
been  arrested,  and  the  wound  carefully  washed,  the  whole  surface  is  covered 
with  charpie  saturated  with  the  solution  in  question,  care  being  taken  that 
the  action  of  the  drug  is  exerted  equally  on  all  parts,  bones  and  vessels,  as 

1  See  the  quotation  from  Vigo,  supra,  page  554. 

2  Fort,  Cours  de  medecine  operatoire,  p.  150.     Paris,  1880. 


DRESSING   THE    STUMP.  597 

well  as  muscles  and  connective  tissue.  Wet  charpie  is  then  placed  outside  to 
diminish  the  irritation  of  the  skin,  and  this  constitutes  the  whole  dressing. 
The  perchloride  of  iron  "combines  with"  the  tissues  with  which  it  is  in  con- 
tact, and  at  the  end  of  twelve  hours  forms  a  thick,  solid  magma,  a  "  touo-h 
cuirass,"  which  completely  isolates  the  subjacent  tissues  from  the  influence 
of  surrounding  agents.  Suppuration  begins  from  the  sixth  to  the  tenth  day 
— sometimes  later — and  the  charpie,  becoming  detached,  leaves  a  sloughy- 
looking  surface  which  soon  becomes  covered  with  healthy  granulations.  "The 
wound  is  then  dressed  with  aromatic  wine,  and  the  flaps  may  be  brought 
together  so  as  to  induce  union  by  "secondary  adhesion." 

Open  Method. — This  mode  of  dressing  stumps,  wjiich,  except  as  to  the  use 
of  sutures,  somewhat  resembles  that  which  I  have  called  the  "air-dressing"' 
of  Teale  and  Humphry,  is  principally  advocated  by  Prof.  James  R.  Wood, "of 
New  York.1 

"  After  a  limb  has  been  amputated,  the  flaps  are  not  even  approximated,  but  left 
entirely  open.  A  pillow  of  oakum  is  placed  under  the  stump,  which  is  allowed  to  rest 
upon  this  support  until  the  wound  is  nearly  healed.  A  small  piece  of  gauze  is  placed 
over  the  contour  of  the  stump,  and  a  cradle  is  placed  over  the  limb,  so  that  the  clothes 
may  not  come  in  contact  with  the  painful  extremity.  This  is  all  the  dressing  that  is 
employed :  no  sutures  are  used  except  in  the  lateral  skin-flap  method,  as  will  be 
described."  [One  or  two  stitches  are  placed  at  the  anterior  angle  of  the  wound,  so  that 
the  flaps  may  cover  the  bone,  but  the  rest  is  allowed  to  gape.]  "  No  adhesive  plaster 
is  employed,  no  oil-silk  is  placed  over  the  stump,  no  bandage  is  applied,  no  dry  charpie 
is  stuffed  into  the  wound,  no  fenestrated  compresses  are  placed  between  the  flaps  ;  in 
other  words,  the  stump  is  left  entirely  alone,  just  as  the  surgeon  made  it  in  his  amputa- 
tion. The  wound  is  thus  allowed  to  drain  freely,  and  the  stump  is  gently  washed  at 
frequent  intervals  by  means  of  an  Esmarch's  wound-douche.  The  water  in  this  irri- 
gator is  impregnated  with  crystals  of  carbolic  acid,  and,  after  this  ablution,  balsam  of 
Peru  (which  makes  a  fine  stimulating  application)  is  poured  over  the  granulating  sur- 
face. The  discharge  which  falls  from  the  wound  is  removed  every  few  hours  in  order 
to  secure  perfect  cleanliness The  stump  is  then  washed  at  frequent  inter- 
nals until  suppuration  has  nearly  subsided  in  the  wound,  and  then  the  flaps  are  gradu- 
ally approximated  by  means  of  strips  of  adhesive  plaster." 

The  historian  of  Prof.  Wood's  cases,  Dr.  F.  S.  Dennis,  professes  his  faith 
in  Pasteur's  and  Lister's  doctrines  as  to  the  evil  effects  produced  by  micro- 
scopic organisms  floating  in  the  air,  but  believes  that  their  bad  influence 
may  be  sufficiently  neutralized  by  frequently  washing  the  stump  with  carbol- 
ized  water  in  the  manner  described.  We  have  next  to  consider  two  modes 
of  dressing  which  aim  at  the  entire  exclusion  of  these  organisms ;  the  antiseptic 
dressing  of  Prof.  Lister,  and  the  loadding-dressing  of  M.  Alphonse  Guerin. 

Antiseptic  Dressing. — In  a  certain  sense,  almost  all  of  the  modern  modes 
of  dressing  wounds  may  be  termed  "antiseptic,"  and  indeed  it  is  not  unusual 
for  the  advocates  of  "Listerism"  to  claim  all  the  good  results  obtained  by  sur- 
geons who  do  not  follow  their  mode  of  practice,  as  due  to  an  unconscious  or 
involuntary  antisepticism,  while  the  bad  results  are  attributed  to  careless  or 
wilful  neglect  of  antiseptic  precautions.  But  hy  the  name  antiseptic  dressing, 
in  this  article,  I  mean  the  peculiar  mode  of  dressing  stumps  advocated  by 
Prof.  Lister,  formerly  of  Glasgow  and  Edinburgh,  but  now  of  King's  College, 
London,  and  founded  in  a  firm  belief  in  the  baleful  influence  of  bacteria  and 
other  micro-organisms,  and  in  the  absolute  necessity  of  excluding  them  from 
the  wound.     The  antiseptic  agent  commonly  employed  is  carbolic  acid,  but 

1  Dennis,  Treatment  of  Amputations  by  the  Open  Method.  New  York  Medical  Journal,  vol. 
xxiii.  p.  8,  187tS. 


598  AMPUTATIONS. 

Prof.  Lister  has  quite  recently  announced  that  an  equally  good  effect  may  be 
obtained  from  the  oil  of  eucalyptus.  The  second  volume  of  this  work  will 
contain  an  Article  specially  devoted  to  the  Antiseptic  System,  and  I  shall  there- 
fore merely  say  in  this  place  that,  the  operation  having  been  performed  under 
a  spray  of  carbolized  steam  (one  to  forty),  and  the  instruments,  sponges,  etc., 
having  been  throughout  kept  thoroughly  antiseptic — the  limb  itself  should 
have  been  first  washed  with  a  1-20  solution  of  carbolic  acid — the  vessels  are 
tied  with  carbolized  catgut,  and  the  wound  (amply  furnished  with  drainage 
tubes)  closed  with  "antiseptic  sutures;"  the  "protective"  dipped  in  a  1-40 
solution  is  next  adjusted,  and  covered  with  one  or  more  layers  of  "antiseptic 
gauze,"  dipped  in  the  same  solution ;  then  with  numerous  layers  of  dry  gauze; 
next  with  one  of  mackintosh ;  and  lastly  with  a  final  layer  of  gauze,  and 
a  bandage  of  the  same  material.  The  outer  dressings  are  not  renewed  until 
the  discharge  has  begun  to  soak  through  them,  while  the  inner  dressings  are 
sometimes  allowed  to  remain  for  weeks  together. 

Wadding  Dressing. — As  in  Prof.  Lister's  dressing  the  bacteria  and  micro- 
cocci are  met  and  destroyed,  in  their  effort  to  reach  the  wound,  by  successive 
layers  of  gauze  impregnated  with  carbolic  acid,  so  by  M.  Guerin's  device 
they  are  mechanically  arrested  by  a  huge  thickness  of  cotton-wadding,  and, 
unable  to  get  either  in  or  out,  miserably  perish  in  its  meshes.  All  hemor- 
rhage from  the  stump  having  been  checked,  M.  Guerin  washes  the  wound, 
and  indeed  the  whole  limb,  with  carbolized  water,  has  it  gently  dried,  and 
held  immovably  in  one  position  by  assistants,  while  the  dressing  is  applied. 
Sutures  may  or  may  not  be  used.  Drainage  tubes  are  not  required.  A  thick 
pad  of  cotton  is  first  placed  over  either  flap,  and  then  two  strips  of  wadding, 
three  inches  wide  and  ten  or  twelve  long,  are  applied  with  their  middle  to 
the  end  of  the  stump,  and  their  extremities  folded  down  upon  the  limb  above 
and  below;  these  strips  are  crossed  by  two  others  of  similar  dimensions,  and 
a  fifth,  applied  circularly,  holds  them  all  in  position.  A  long  band  of  wad- 
ding is  then  employed  like  a  bandage,  to  completely  cover  in  the  stump  and 
the  limb  to  a  point  half  way  between  the  two  nearest  joints;  the  amount  of 
cotton  used  is  to  be  enough  to  make  the  diameter  of  the  covered  limb  at  least 
three  times  that  which  it  naturally  possesses.  Ordinary  bandages  are  next 
applied  over  the  wadding,  the  first  turns  being  quite  loose,  and  the  bandages 
then  gradually  made  more  and  more  tight,  until  the  final  turns  exercise  a 
very  energetic  but  equable  compression  over  the  whole  stump.  Usually 
thirteen  bandages  of  eleven  yards  each  are  required  for  this  purpose.  When 
the  dressing  is  complete,  the  limb  can  be  moved  in  any  direction,  or  the 
stump  struck,  without  giving  the  patient  any  pain.  If  in  the  course  of  a  fewr 
hours,  any  blood  is  found  leaking  through  the  bandages,  a  thick  square  of 
wadding  and  an  additional  bandage  are  applied.  The  dressing  must  be  ex- 
amined every  day  during  the  first  week,  and,  if  necessary,  still  more  bandage 
added  so  as  to  keep  up  firm  compression.  The  dressing  is  allowed  to  remain, 
as  a  rule,  for  from  twenty  to  twenty-five  days;  it  should  be  applied,  and, 
when  necessary,  reapplied,  in  a  special  room  and  not  in  the  ordinary  ward.1 

For  want  of  space  I  can  merely  mention  the  "Bordeaux  3fethod"  wdiich 
may  !><•  considered  as  in  sonic  degree  a  combination  of  Lister's  and  Guerin's 
plans,  embracing  ihc  \\m~  of  drainage  tubes,  very  accurate  adjustment  of  the 
flaps  with  sutures  and  collodion,  washing  the  stump  with  carbolized  water, 
and  covering  it  with  cotton  ;2  and  the  Earth  Dressing  of  Dr.  Addinell  Hewson,3 

1  Fort,  op.  cit.,  pp.  159  >t  seq.  2  Ibid.,  p.  177. 

3  Earth  as  a  topical  application  in  Surgery.     Philadelphia,  1872. 


DRESSING   THE   STUMP.  599 

which,  as  its  name  implies,  consists  in  the  use  of  prepared  earth  or  dried  clay, 
placed  in  immediate  contact  with  the  wound. 

What  is  the  legitimate  inference  to  be  derived  from  a  consideration  of  the 
various  and  very  dissimilar  methods  of  dressing  stumps  which  have  now- 
been  referred  to — methods,  it  must  be  remembered,  which  have  been,  each 
without  exception,  lauded  by  their  promoters  as  superior  to  all  others,  and, 
in  the  opinion  of  their  advocates,  proved  to  be  so  by  the  unerring  test  of 
clinical  experience?  Is  it  not  that  the  particular  mode  in  which  a  stump  is 
dressed  is,  after  all,  of  comparatively  little  importance,  and  that  we  must 
look  for  information  as  to  the  probable  result  of  an  amputation,  rather  to  the 
nature  of  the  lesions  which  render  the  operation  necessary,  and  the  consti- 
tutional condition  of  the  patient,  than  to  the  influence  of  any  extraneous 
circumstances?  This  question  will  be  referred  to  again  when  we  come  to 
consider  the  statistics  of  amputation,  and  is  merely  suggested  here  in  con- 
nection with  the  mode  of  treatment  next  to  be  described,  and  which  I  have 
ventured  to  call  the  simple  dressing  for  amputation  wounds. 

Simple  Dressing. — In  the  first  place,  let  us  consider  what  are  the  requisites 
for  a  good  stump  dressing.  There  must  obviously  be  ample  means  provided 
for  drainage;  or  pain,  if  not  worse,  will  be  caused  by  the  accumulation  and 
retention  of  the  sero-sanguineous  flow  which  inevitably  follows  an  amputa- 
tion. Hence,  as  already  mentioned,  care  must  be  taken  not  to  apply  the 
stitches  too  close  together,  and,  if  sufficient  drainage  be  not  afforded  by  the 
ligatures,  one  or  two  fenestrated  India-rubber  tubes  may  be  laid  in  the  wound 
and  brought  out  at  the  angles.  Then,  whatever  dressing  is  employed  should 
not  be  liable  to  stick  to  the  wound,  lest  it  interfere  with  the  exit  of  discharges 
and  cause  pain  when  it  is  renewed ;  hence  wet  dressings  are  preferable  to  salves 
or  ointments,  and  upon  the  whole  I  know  of  nothing  which  answers  a  better 
purpose  than  pure  laudanum,  the  use  of  which  in  dressing  stumps  I  learned 
many  years  ago  from  that  excellent  surgeon  Dr.  Joseph  Pancoast.  The  lau- 
danum is  no  doubt  antiseptic,  from  the  alcohol  which  it  contains,  and  its  use 
is  certainly  very  soothing  to  the  patient ;  it  prevents,  to  a  great  extent,  if  not 
entirely,  that  painful  jerking  of  the  stump  which  is  so  apt  to  follow  ampu- 
tation. Mr.  Bryant  accomplishes  the  same  purpose  by  bandaging  the  stump 
firmly  to  a  padded  splint,  but  with  the  laudanum  dressing  this  is  unnecessary, 
and  the  stump  will  be  found  to  rest  very  comfortably  upon  a  soft  pillow, 
which  should  be  covered  with  a  piece  of  India-rubber  cloth  and  a  clean  towel. 
At  the  second  dressing,  forty-eight  hours  after  the  operation,  I  commonly 
substitute  diluted  alcohol  for  the  laudanum,  and  continue  this  dressing  until 
the  wound  is  nearly  healed,  after  which  the  ointment  of  the  oxide  of  zinc 
may  be  employed  instead.  While  my  preference  is  for  pure  laudanum,  as  a 
first  dressing,  I  have  occasionally  used,  with  excellent  results,  diluted  lau- 
danum, or  lead-water  and  laudanum,  or  simply  olive  oil.  I  have  no  particu- 
lar objection  to  carbolized  oil,  if  it  be  not  so  strongly  impregnated  with  the 
acid  as  to  produce  irritation  of  the  skin,  but  have  seen  no  advantage  from  its 
employment. 

Whatever  material  be  employed  for  the  dressing,  this  must  be  kept  moist; 
otherwise  it  will  adhere  to  the  edges  of  the  wound  and  produce  irritation. 
This  object  is  best  accomplished  by  saturating  with  whatever  preparation  is 
employed,  a  large  piece  of  lint,  laying  it  underneath  the  stump,  folding  it  over 
the  end,  and  then  again  (doubled)  from  either  side,  so  that  on  top  of  the  stump 
are  placed  five  layers  of  wet  lint,  constituting  a  reservoir  from  which  the 
medicated  fluid  is  gradually  drawn  downwards.  The  whole  should  be  covered 
moreover  with  oiled  silk,  or  some  other  impermeable  tissue  which  will  keep 


600  AMPUTATIONS. 

the  part  moist  for  at  least  forty-eight  hours.  After  the  second  dressing,  I 
renew  the  applications  every  day,  and  the  waxed  paper  (which  is  much 
cheaper  than  oiled  silk)  may  conveniently  be  substituted.  As  long  as  wet 
dressings  are  employed,  no  pads  of  charpie  or  oakum  are  necessary,  but  the 
dressing,  with  its  impermeable  envelope,  may  be  simply  held  in  position  by 
the  turns  of  a  light,  loosely  applied,  recurrent  bandage.  In  the  later  stages 
of  the  case,  when  the  wound  is  dressed  with  zinc  ointment,  a  little  oakum 
may  be  loosely  applied  externally,  as  a  means  of  mechanical  protection. 

After-treatment  of  the  Stump. — When  the  dressings  are  to  be  removed,  the 
bandage  should  be  cut,  and  the  oiled  silk  and  lint  laid  off  from  the  stump 
before  this  is  raised  from  the  pillow  ;  the  surgeon  at  the  same  time  examines 
the  sutures,  untwisting  or  cutting  any  that  are  too  tight,  and,  if  a  plug  of 
wax  has  been  applied  to  the  medullary  Cavity  of  the  bone,  gently  withdraws 
it  by  pulling  on  the  wire  to  which  it  is  attached.  An  assistant  then  slips  his 
hand  under  the  stump,  carrying  it  well  down  towards  the  end,  and  then 
firmly  but  gently  lifts  the  part,  and  supports  it  while  the  soiled  dressings  are 
removed,  the  stump  washed  and  dried,  and  the  new  dressings  adjusted.  This 
is  not  a  painful  process ;  patients  often  dread  the  manipulation  beforehand, 
but  it  is  very  seldom  that  they  complain  at  the  time,  and  they  almost  in- 
variably experience  a  decided  increase  of  comfort  when  the  dressing  is  com- 
pleted. 

The  icashing  of  the  stump  is  to  be  very  gently  effected  with  a  clean  soft 
sponge,  or  bunch  of  tow  or  oakum — the  late  Mr.  Callender  employed  a  camel's 
hair  brush — and  tepid  water,  colored  with  a  little  Condy's  fluid  (solution  of 
permanganate  of  potassium),  which  is  an  excellent  deodorizer  and  disinfect- 
ant. As  far  as  possible,  the  water  should  be  allowed  to  flow  over  the  stump 
without  touching  this  with  the  sponge  itself.  The  part  is  then  gently  sopped 
until  it  is  dry,  with  a  clean,  soft  towel,  and  the  new  dressings  adjusted. 
When  the  wound  has  fairly  well  healed,  and  the  stump  is  no  longer  sensitive, 
the  washing  may  be  more  thorough — a  little  oil  of  turpentine  being  employed 
to  remove  the  adhesive  plaster  which  sticks  to  the  skin,  and  the  whole  well 
douched  afterwards  with  soapsuds  and  water. 

If  silk  sutures  have  been  used,  they  may  be  properly  taken  away  on  the 
third  or  fourth  day  ;  metallic  sutures  may  be  allowed  to  remain  much  longer, 
indeed  often  until  the  wound  is  firmly  healed.  The  ligatures  should  be  allowed 
to  drop  of  themselves,  but  the  surgeon  may  gently  feel  them,  to  ascertain  if 
they  are  loose,  after  a  week  in  the  case  of  the  smaller,  and  after  ten  days  in 
that  of  the  larger  vessels.  Under  no  circumstances  should  a  ligature  be  rudely 
-pulled  away.  Apart  from  the  risk  of  hemorrhage,  I  have  more  than  once 
known  the  somewhat  forcible  withdrawal  of  a  ligature,  attended  by  slight 
bleeding,  showing  that  the  granulating  surface  had  been  broken,  to  be  fol- 
lowed in  a  few  hours  by  a  chill  and  the  development  of  fatal  pyaemia.  If  short 
cut  animal  ligatures  have  been  employed,  they  are  commonly  dissolved  in  the 
fluids  of  the  stump,  and  are  not  seen  after  the  operation.  If  acupressure  has 
been  used,  the  pins  or  needles  may  be  taken  from  the  smaller  vessels  on  the 
second,  and,  from  the  larger,  on  the  third,  fourth,  or  fifth  day,  according  to 
circumstances.  If  drainage  tubes  have  been  employed,  they  may  be  withdrawn 
about  the  end  of  the  first  week. 

I  have  called  this  the  simple  dressing  for  stumps,  but,  it  may  be  asked,  is 
not  the  air-dressing  simpler  still  ?  jSTo  doubt  it  is — inasmuch  as  nothing  is 
less  than  something — but  I  do  not  think  it  as  satisfactory.  Prof.  Humphry's 
remark  as  to  the  rapid  healing  of  face  wounds  is  certainly  true  ;  but  it  is  also 
true  that  face  wounds  heal  quite  as  rapidly,  and  with  much  less  discomfort  to 


STRUCTURE   AND   DISEASES   OF   STUMPS.  G01 

the  patient,  if  covered  with  a  strip  of  lint  kept  wet  with  glycerine  and  water, 
than  if  left  dry.  Moreover,  I  had  the  opportunity,  some  years  ago,  of  seeing 
a  number  of  amputations  treated  after  Teale's  method  by  a  very  careful  sur- 
geon, and  I  can  honestly  say  that  I  have  never  seen  so  large  a  proportion  of 
inflamed  and  sloughing  stumps  before  or  since.  I  have  no  doubt  that  Prof. 
Wood's  "  open  method"  is  better  than  Teale's  or  Humphry's,  as  avoiding  any 
risk  of  undue  tension  by  sutures ;  but  the  abandonment  of  all  effort  to  obtain 
primary  union  seems  to  me  to  be  a  step  in  the  wrong  direction,  and  one  not 
compensated  for  by  any  other  feature  of  the  plan  in  question.  Besides,  I 
believe  that  positive  benefit  is  derived  from  the  constant  contact  of  an 
anodyne  fomentation. 


Structure  and  Diseases  of  Stumps. 

Structure  of  Stumps. — When  first  formed,  a  stump  contains  all  the  tissues 
utilized  in  the  amputation  (unless  these  have  sloughed  before  the  occurrence 
of  cicatrization),  but  soon  afterwards  various  changes  are  observed,  which 
continue  progressively  for  a  long  time  afterwards.  Thus  the  muscular  sub- 
stance gradually  disappears,  and,  no  matter  how  full  and  plump  the  stump 
may  have  seemed  at  first,  it  in  time  assumes  a  withered  look,  and  the  skin 
forms,  as  it  were,  a  loose  bag  around  the  end  of  the  bone.  The  fibrous  and 
tendinous  portions  of  the  muscles  remain,  however,  and  undergo  conversion 
into  a  dense  fibre-cellular  mass  which  protects  the  bone,  and  renders  it  less 
liable  to  cause  ulceration  of  the  overlying  skin  or  cicatricial  tissue  when  sub- 
jected to  pressure.  The  bone  itself  undergoes  changes,  becoming  rounded  off, 
and  a  button  of  new  osseous  tissue  closing  the  medullary  cavity,  which  is  to 
a  great  extent  obliterated.  The  vessels,  at  first  filled  with  clots  reaching  to 
the  nearest  anastomosing  branches,  become  in  time  changed  into  firm  fibrous 
cords,  continuous  with  the  vessels  above.  The  nerves  are  thickened,  and 
become  bulbous  at  their  extremities,  constituting  a  form  of  neuroma;  these 
bulbous  enlargements  consist  mainly  of  fibro-cellular  tissue,  but  are  abund- 
antly supplied  with  nerve  fibrils. 

In  connection  with  these  alterations  of  structure,  met  with  in  the  stump 
itself,  very,  curious  changes  have  been  noted  in  distant  organs.  Thus  Dr. 
Dickinson,  Dr.  Lockhart  Clarke,  and  M.  Vulpian,  have  observed  localized 
atrophy  of  the  spinal  cord  which  corresponds  to  the  side  on  which  the  ampu- 
tation has  been  practised,  and  similar  changes  have  likewise  been  noticed  by 
Drs.  Webber,  Genzmer,  Dickson,  Leyden,  and  Dreschfield.  Berard,  many 
years  ago,  observed  atrophy  of  the  anterior  roots  of  the  spinal  nerves  cor- 
responding to  the  amputated  part,  and  Chuquet  and  Luys  have  observed 
atrophy  of  the  brain  on  the  side  opposite  to  that  of  the  amputation. 

A  patient  who  has  submitted  to  one  of  the  large  amputations  is  apt  to 
become  fat:  this  is  apparently  due  to  the  fact  that,  while  the  supply  of  nutri- 
ment continues  the  same  as  before  the  operation,  the  demand  for  it  is  dimin- 
ished by  a  part  of  the  body  having  been  removed,  and  accumulation  of  fat  is 
the  consequence ;  this  is  still  further  aided,  in  the  case  of  amputations  of  the 
lower  extremity,  by  the  resulting  inability  to  take  the  proper  amount  of 
exercise.  Among  patients  of  the  lower  class,  the  enforced  idleness  which 
often  follows  as  a  necessary  sequel  of  amputation,  is  unfortunately  apt,  in 
many  cases,  to  lead  to  the  formation  of  intemperate  habits. 

Diseases  of  Stumps. — Any  of  the  tissues  which  enter  into  the  structure  of 
a  stump  may  be  morbidly  affected  and  give  rise  to  pain  or  other  annoyance. 


602  AMPUTATIONS. 

Sloughing  of  the  skin  and  connective  tissue  which  cover  the  stump,  is  occa- 
sionally met  with,  and  may  be  due  to  bruising  of  the  parts  by  the  injury 
which  rendered  the  amputation  necessary ;  to  undue  tension,  from  original 
insufficiency  of  covering,  or  from  subsequent  swelling  conjoined  with  too 
tight  closure  of  the  wound  by  sutures,  etc.;  or  to  constitutional  causes,  as  in 
cases  of  senile  gangrene,  or  of  that  frightful  affection  which  has  already  been 
alluded  to,  the  true  "  traumatic  or  spreading  gangrene."  Sloughing  is  more  apt 
to  occur  after  flap  amputations  than  after  those  done  by  the  circular  method  ; 
but  I  have  once  seen  the  entire  cuff  of  a  circular  operation  slough  off  as 
cleanly  as  if  it  had  been  cut  by  a  knife.  The  treatment  of  a  sloughing  stump 
consists  in  removing  all  sources  of  tension,  by  cutting  stitches,  etc.,  and  apply- 
ing a  fermenting  or  charcoal  poultice  till  the  dead  parts  are  removed,  when 
an  attempt  may  be  made  to  diminish  the  size  of  the  remaining  wound  by  the 
judicious  use  of  strapping. 

Erysipelas  or  Diffuse  Cellulitis  may  attack  a  stump,  and  either  forms  a 
serious  complication.  The  treatment  consists  in  removing  all  the  sutures, 
applying  a  soothing  dressing  (such  as  diluted  alcohol,  or  olive  oil),  wrapping 
the  limb  in  cotton,  and  administering  full  doses  of  the  tincture  of  the  chloride 
of  iron,  which  may  be  conveniently  combined  with  the  solution  of  acetate  of 
ammonium,  as  in  the  following  formula : — R.  Tinctune  ferri  chloridi  f3j-f3ijj 
syrupi  f §ss,  liquoris  ammonii  acetatis  f^vss.  M.  Sig.  "  A  tablespoonful 
every  two  hours." 

Hospital  Gangrene  is  a  very  serious  affection  when  following  a  recent  ampu- 
tation, but  is  fortunately  not  very  common  at  the  present  day.  The  treatment 
consists  in  thoroughly  cauterizing  the  whole  surface  of  the  wound  with  bro- 
mine or  a  strong  solution  of  permanganate  of  potassium  (3j  to  f  Sj),  and 
bringing  the  patient  under  the  constitutional  effect  of  opium.  AVhen  the 
disease  is  arrested,  the  wound  will  often  heal  with  great  rapidity,  but  occa- 
sionally the  destruction  of  tissue  may  have  been  so  great  as  to  necessitate  a 
second  operation. 

Spasm  of  the  muscles  of  a  stump  is  a  painful  complication,  which  is  chiefly 
nit  I  with  a  few  hours  after  the  recovery  from  anaesthesia,  and  which,  by 
causing  the  limb  to  bo  jerked  off  the  pillow  on  which  it  rests,  tends  to  inter- 
fere with  primary  union.  The  treatment  ordinarily  recommended,  is  the 
application  of  a  tolerably  firm  bandage,  with  or  without  a  splint,  and  the 
interna]  administration  of  anodynes.  As  already  mentioned,  this  complica- 
tion is  very  seldom  met  with  when  the  laudanum  dressing  is  employed.  Cases 
of  persistent  and  intractable  choreic  spasm  of  a  stump,  occurring  some  time 
after  amputation,  have  been  recorded  by  Dr.  S.  "Weir  Mitchell  and  Dr.  H.  C. 
Wood. 

"Retraction  of  the  musdes  sometimes  occurs  and  continues  progressively  for 
many  days  or  even  weeks  after  an  amputation,  and  occasionally  constitutes  a 
really  serious  complication  by  interfering  with  the  healing  of  the  stump, 
causing  troublesome  ulceration  of  the  cicatrix  (if  healing  has  already  oc- 
curred),  and  giving  the  part  a  peculiar,  pointed  appearance  which  has  sug- 
gested  the  name  of  conical  or  sugar-loaf  stump,  &  condition  which  may  also 
depend  upon  sloughing,  <>r  upon  hypertrophy  of  the  bone.  The  ulcer  on  the 
end  of  the  stump,  caused  by  muscular  contraction,  is  called  the  meclianical 
ulcer,  and  is  often  very  intractable.  The  treatment  consists  in  the  application 
of  a  firm  circular  bandage,  from  above  downwards,  so  as  to  relieve  tension 
by  restraining  the  action  of  the  muscles,  and,  as  it  were,  coaxing  the  soft 


STRUCTURE   AND   DISEASES   OF   STUMPS.  603 

parts  downwards,  until  the  ulcer  has  had  time  to  heal.  Another  plan  is  to 
employ  extension  by  means  of  a  weight,  applied  either  with  the  ordinary 
adhesive  plaster  stirrup,  as  in  fractured  thigh,  or,  as  advised  by  Mr.  Bryant 
through  the  medium  of  an  arched  splint  attached  to  the  front  and  back  of 
the  limb.  The  last  resort,  in  a  case  of  conical  stump  which  is  constantly  re- 
ulcerating,  or  which  is  too  tender  to  permit  the  use  of  an  artificial  limb,  is 
resection  of  two  or  more  inches  of  the  end  of  the  bone;  an  operation  which 
happily  is  attended  with  very  little  risk,  and  of  which  the  result  is  usually 
quite  satisfactory. 

Contraction  of  the  tendons  in  the  neighborhood  of  the  stump  may  cause 
trouble,  by  giving  rise  to  deformity  and  dragging  upon  the  cicatrix  ;  this  is 
particularly  observed  in  connection  with  the  medio-tarsal,  or  Chopart's,  ampu- 
tation of  the  foot,  after  which  operation,  the  natural  arch  of  the  foot  being 
destroyed,  the  tenclo  Achillis  may  be  drawn  upwards  by  the  gastrocnemius 
and  soleus  muscles,  and  a  painful  form  of  talipes  equinus  result,  the  cicatrix 
being  forced  against  the  sole  of  the  shoe  in  walking.  This  occurrence  can 
usually  be  prevented  by  taking  care  to  make  the  flaps  of  ample  size,  and  by 
the  judicious  use  of  bandages,  splints,  and  weight  extension,  if  any  tendency 
to  retraction  be  noticed.  Tenotomy  may  be  resorted  to  if  other  means  prove 
insufficient. 

Hemorrhage  from  a  stump  may  occur  at  any  time  before  the  wound  is  com- 
pletely healed,  though  it  is  not  usually  looked  for  after  the  safe  separation  of 
all  the  ligatures.  I  have,  however,  known  fatal  hemorrhage  from  the  femoral 
artery,  in  a  syphilitic  subject,  to  occur  four  weeks  after  amputation  of  the 
thigh,  and  when  all  the  ligatures  had  come  away  and  the  patient  had  been 
going  about  for  some  time.  Sometimes  the  bleeding  comes  from  small  ves- 
sels which  were  not  noticed  at  the  time  of  the  operation,  but  which  begin  to 
spout  when  reaction  occurs  (consecutive  or  reactionary  hemorrhage).  Secondary 
hemorrhage  from  a  stump  may  be  due  to  the  bleeding  vessel  having  been 
imperfectly  secured  in  the  first  instance — as  by  tying  it  too  near  the  cut  end, 
so  that  the  noose  can  slip  off  before  repair  is  complete,  or  by  including  too 
much  tissue  with  the  artery,  so  that  in  a  day  or  two  the  knot  becomes  loose — 
or  to  a  diseased  condition  of  the  arterial  coats  themselves,  rendering  them 
liable  to  ulceration,  or,  more  rarely,  to  the  formation  above  the  ligature  of 
an  aneurismal  swelling  which  subsequently  undergoes  rupture.  Capillary 
oozing  or  parenchymatous  hemorrhage  sometimes  occurs  after  amputation,  and 
appears  to  be  due  to  thrombosis  of  the  venous  trunks  interfering  with  the 
return  circulation.  The  treatment  of  hemorrhage  from  a  stump,  if  the  bleed- 
ing be  but  slight  in  amount,  consists  in  elevating  the  part  and  applying  cold 
(by  means  of  an  ice-bag),  and  moderate  pressure,  and  in  administering  ergot, 
digitalis,  and  opium;  but  if  these  means  fail,  or  if  it  appear  that  a  la  rue 
vessel  is  bleeding,  more  decided  measures  must  be  adopted.  If  the  pro- 
cess of  healing  be  not  far  advanced,  the  stump  should  be  reopened,  the 
surgeon  breaking  up  the  recent  adhesions  with  his  fingers,  and  the  bleed- 
ing artery  should  then  be  tied  in  the  wound,  it  being  sometimes  necessary 
for  this  purpose  to  dissect  the  vessel  up  for  a  short  distance,  and  thus 
free  it  from  the  surrounding  tissues.  If,  however,  the  hemorrhage  has  not 
occurred  until  the  greater  part  of  the  stump  is  firmly  healed,  it  will  probably 
be  better  to  secure  the  artery  immediately  above  the  wound  rather  than  in  the 
wound  itself;  this  may  be  done  by  cutting  down  and  applying  a  ligature,  but 
may  be  much  more  readily  accomplished  by  acupressing  the  vessel  according 
to  Simpson's  first  method — passing  a  long  pin  deeply  across  the  known  course 
of  the  vessel,  so  as  to  go  below  it,  and,  if  necessary,  increasing  the  pressure 
by  applying  a  pad  of  lint  or  cork,  and  a  figure-of-eight  ligature,  externally. 


604  AMPUTATIONS. 

This  is  one  of  the  few  cases  in  which  acupressure  seems  to  me  to  possess 
greater  advantages  than  the  ligature,  and  I  would  urgently  recommend  it  as 
the  best  means  of  controlling  hemorrhage  under  these  circumstances ;  the  pin 
can  be  introduced  without  the  necessity  of  etherizing  the  patient,  and  the 
operation,  when  the  patient  is  already  very  much  weakened  by  bleeding,  is 
altogether  a  much  less  formidable  one  than  cutting  down  and  searching  for 
the  artery.  Ligation  of  the  main  artery  at  a  distance  from  the  wound, 
though  recommended  by  Liston,  is  now  generally  regarded — and  I  think 
justly — as  a  bad  operation,  particularly  in  the  lower  extremity ;  it  adds  a 
serious  complication  in  itself,  exposes  to  considerable  risk  of  gangrene,  and 
is  moreover  often  ineffectual  in  permanently  arresting  the  hemorrhage ;  in 
the  upper  extremity,  it  may  be  sometimes  resorted  to  with  advantage,  but 
when  the  lower  limbs  are  concerned  a  better  plan  is  to  acupress  the  vessel  in 
the  way  already  described,  and,  if  necessary,  re-amputate  when  the  patient 
has  rallied  enough  to  bear  a  second  operation. 

Aneurismal  enlargement  of  the  arteries  of  a  stump  has  already  been  alluded 
to  as  being  an  occasional  cause  of  hemorrhage.  Mr.  Erichsen,  in  his  "  Science 
and  Art  of  Surgery,"  describes  and  figures  a  remarkable  case  of  aneurismal 
varix  occurring  after  amputation  at  the  ankle. 

Neuromata,  or  painful  nerve-tumors,  are  often  met  with  in  stumps.  The 
bulbous  enlargements  of  the  cut  ends  of  the  nerves  occur,  indeed,  as  already 
pointed  out,  in  all  stumps,  but  the  term  neuroma  is  not  ordinarily  employed, 
unless  these  enlargements  are  painful.  The  pain,  which  in  these  cases  is 
sometimes  very  distressing,  is  due,  according  to  Weir  Mitchell,  to  the  exist- 
ence of  a  true  neuritis,  or  of  a  state  of  sclerosis  which  results  from  inflam- 
matory changes.  The  treatment  is  unfortunately  not  very  satisfactory ;  if  the 
pain  were  evidently  connected  with  any  distinct  tumor,  resection  of  the 
growth,  and  of  two  or  three  inches  of  the  nerve  with  which  it  was  connected, 
would  be  indicated ;  under  other  circumstances,  it  would  be  proper  to  cut 
down  and  forcibly  stretch  the  nerve  which  supplied  the  painful  region,  or,  if 
this  failed,  to  excise  a  couple  of  inches  from  the  continuity  of  the  nerve  and 
turn  its  distal  end  downwards,  so  as  to  prevent  reunion  ;  or,  if  the  whole  face 
of  the  stump  seemed  to  be  neuralgic,  a  re-amputation  might  be  properly  re- 
sorted to.  These  various  operations,  however,  though  perfectly  justifiable 
under  the  circumstances  supposed,  by  no  means  insure  complete  relief  from 
suffering.  The  late  Dr.  Nott  placed  on  record  a  remarkable  case  in  which 
the  patient  submitted  to  no  less  than  three  re-amputations  of  a  neuralgic 
stump,  and  three  nerve-excisions,  and  yet  was  not  cured  at  the  end  of  this 
persevering  treatment.  As  palliative  measures,  where  an  operation  is  not  con- 
sidered necessary,  the  application  of  leeches,  ice,  and  counter-irritants,  may 
be  of  service,  as  may  the  topical  use  of  the  strong  tincture  of  aconite  root,  or 
hypodermic  injections  of  morphia.  Relief  was  obtained,  in  a  case  recorded 
by  Girard,  by  the  repeated  employment  of  electro-puncture. 

Periostitis,  osteitis,  or  osteomyelitis,  or  all  of  these  affections  simultaneously, 
may  attack  the  bone  of  a  stump,  and  in  some  cases  may  lead  to  very  serious 
consequences.  Subperiosteal  suppuration,  unless  the  pus  be  promptly  evacuated 
by  a  free  incision,  is  apt  to  lead  to  extensive  necrosis,1  and  sometimes,  by  im- 
plicating the  epiphyseal  junction,2  or  even  secondarily  the  neighboring  joint, 

1  Subperiosteal  suppuration  sometimes  receives  the  name  of  acute  necrosis,  but  the  necrosis  is  a 
consequence  of  the  disease  rather  than  the  disease  itself. 

2  The  sequence  of  events  is  usually  the  other  way,  epiphysitis  preceding  subperiosteal  suppura- 
tion. (See  Macnamara,  Lectures  on  Diseases  of  Bones  and  Joints,  pp.  (j'J,  75.  Second  edition.  Lon- 
don, 18bl..j 


STRUCTURE   AND   DISEASES   OF   STUMPS.  605 

may  place  the  patient's  life  in  jeopardy,  and  require  re-amputation.  Diffuse 
suppurative  osteomyelitis  is  always  a  very  grave  affection,  often  ending  in 
pyaemia  and  death,  and  particularly  when  it  occurs  in  the  femur,  a  bone  spe- 
cially exposed  to  this  destructive  form  of  inflammation  when  its  medullary 
cavity  is  laid  open,  as  it  necessarily  must  be  in  most  amputations  of  the  thigh. 
Konig  reports  a  cure,  in  a  ease  of  this  kind,  effected  by  scooping  out  the  dis- 
eased medulla  and  stuffing  the  cavity  with  cotton  saturated  with  a  strong 
solution  of  chloride  of  zine ;  but,  ordinarily,  the  best  mode  of  treatment  con- 
sists in  re-amputating  at  the  nearest  joint — an  operation  which,  though  appa- 
rently of  a  desperate  character,  has  proved  very  sueeessfnl  in  the  hands  of 
Roux  and  Arlaud,  and  has  been  advantageously  resorted  to  by  Sir  J.  Fayrer, 
even  after  the  development  of  pyemic  symptoms. 

Necrosis  is  a  very  common  affection  of  stumps.  In  most  cases  the  death 
of  bone  is  limited  to  a  more  or  less  perfect  ring,  corresponding  to  the  line  of 
section,  and  is  apparently  due  to  the  bruising  of  the  part  by  the  teeth  of  the 
saw ;  when,  however,  the  necrosis  follows  upon  osteitis,  subperiosteal  suppu- 
ration, or  osteomyelitis — or  all  combined — it  is  sometimes  very  extensive,  and 
may  involve  almost  all  that  remains  of  the  shaft  of  the  bone.  Every  patho- 
logical or  surgical  museum  embraces  specimens  of  the  long,  conical,  and  often 
tubular  sequestra  which  are  found  under  these  circumstances,  and  which  are 
simply  the  result  of  inflammatory  action  of  a  high  grade.  An  ingenious 
attempt  has  been  made  to  explain  the  occurrence  of  these  sequestra  by  attri- 
buting it  to  injury  of  the  nutritious  artery,  which  is,  of  course,  often  divided  in 
amputations ;  but  it  seems  to  have  been  overlooked  that  a  precisely  similar 
form  of  necrosis  occurs  as  a  result  of  osteitis  in  cases  in  which  no  operation 
at  all  has  been  performed.  Not  only  is  the  sequestrum  often  tubular,  but  it 
is  not  unfr3  juently  lined,  as  well  as  surrounded,  with  living  bone — the  medulla 
undergoing  a  retrograde  metamorphosis  into  osseous  tissue  at  the  same  time 
that  an  involucrum  is  being  formed  by  the  periosteum.  This  fact  was  long 
ago  observed  by  Copland  Hutchison,1  and  more  recent  illustrations  have 
been  recorded  by  several  writers,  including  M.  Demarquay,  of  Paris,  Prof. 
Markoe,  of  New  York,  and  Dr.  Packard,  of  this  city;  the  first  philosophical 
explanation  of  the  occurrence  appears  to  have  been  given  by  M.  Oilier,  of 
Lyons.  The  treatment  of  necrosis  in  a  stump  consists  in  removing  the  seques- 
trum as  soon  as  it  has  become  loose ;  this  can  usually  be  effected  without 
difficulty  by  simply  seizing  the  sequestrum  with  forceps,  and  drawing  it  out 
with  a  rocking  or  twisting  motion;  occasionally,  however,  the  dead  bone 
may  be  firmly  held  in  place  by  the  periosteal  formation  of  new  bone  around 
it,  or  even  by  osseous  bands  extending  from  this  to  the  ossified  medulla — 
under  which  circumstances  the  involucrum  must  be  cut  away  until  the  source 
of  obstruction  is  removed.  Under  no  circumstances  can  simple  necrosis  in  a 
stump,  no  matter  how  extensive,  necessitate  re-amputation.  This  operation 
may,  however,  as  already  mentioned,  be  required  by  what  is  sometimes  called 
acute  necrosis,  but  which  should  more  properly  be  termed  diffuse  subperiosteal 
suppuration. 

Caries  is  sometimes  met  with  in  the  bone  of  a  stump,  usually  when  the  am- 
putation has  been  performed  for  scrofulous  or  syphilitic  disease,  or,  if  for  injury, 
when  the  patient  is  a  subject  of  one  of  these  diatheses.  The  treatment,  lie- 
sides  the  adoption  of  suitable  constitutional  measures,  consists  in  injecting 
the  sinuses  which  lead  to  carious  bone,  with  tincture  of  iodine,  one  of  the 
mineral  acids  properly  diluted,  or,  which  I  have  sometimes  used  with  advan- 

1  Some  Practical  Observations  in  Surgery,  illustrated  by  cases,  page  130.     London,  1816. 


606  AMPUTATIONS. 

tage,  the  preparation  introduced  by  M.  Notta  under  the  name  of  the  "  Liqueur 
de  Villate,"  which  may  be  made  according  to  the  following  formula  :  R.  Zinci 
sulphatis,  cupri  sulphatis,  aa  gr.  xv  ;  liquoris  plunibi  subacetatis,  f^ss  ;  acidi 
acetici  diluti  vel  aceti  albi,  f3iijss. — M.  As  a  last  resort,  the  stump  may  be 
laid  open  and  the  carious  bone  removed  with  osteotrite  and  gouge,  or,  possibly, 
a  re-amputation  may  be  found  necessary. 

Hypertrophy  of  the  bone  after  an  amputation,  has  already  been  alluded  to  as 
one  of  the  causes  of  a  conical  or  sugar-loaf  stump.  This  is  observed  in  patients 
who  have  not  attained  their  full  growth,  and  principally  in  amputations  of 
the  leg  and  upper  arm  ;  its  occurrence  in  these  rather  than  in  other  situations, 
is  accounted  for  by  the  well-known  physiological  fact  that,  owing  to  the  direc- 
tion taken  by  the  nutritious  arteries  in  the  several  bones,  and  the  consequent 
period  at  which  the  epiphyses  become  united  to  the  diaphyses,  the  chief 
growth  of  the  lower  extremity  is  from  tne  epiphyses  in  proximity  to  the  knee, 
while  that  of  the  upper  extremity  is  from  those  of  the  wrist  and  shoulder. 
Hence  amputations  of  the  thigh  and  forearm  remove  the  principal  sources  of 
growth  for  the  portions  of  bone  which  remain,  while  amputations  of  the 
upper  arm  and  leg  leave  these  sources  of  growth,  and  in  a  few  years  the  bones 
of  stumps  in  these  situations  may  be  too  long  for  the  soft  parts  which  were 
originally  ample  for  their  covering.  If  any  treatment  is  required  in  a  case  of 
this  kind,  resection  of  the  overgrown  bone  is  the  only  remedy  likely  to  be  of 
service. 

Adventitious  bursce  are  sometimes  formed  over  the  bones  of  stumps  from 
pressure  of  the  pad  or  artificial  limb  used  in  walking.  If  such  a  bursa  should 
become  painful,  the  mechanical  arrangement  of  the  prothetic  apparatus  em- 
ployed should  be  altered,  so  as  to  relieve  the  part  from  pressure;  and  if  this 
be  not  sufficient,  an  attempt  may  be  made  to  cause  obliteration  of  the  bursa 
by  injecting  tincture  of  iodine,  or  establishing  a  seton ;  or  excision  of  the 
bursa  itself  may  be  resorted  to. 


Prothetic  Apparatus  and  the  Adaptation  of  Artificial  Limbs. 

One  of  the  earliest  records  which  we  have  of  a  successful  effort  to  supply 
the  place  of  an  entire  limb  lost  by  amputation,  is  given  in  the  history  of 
Francois  de  la  Noue,  a  celebrated  Huguenot  officer,  born  A.  D.  1531,  who 
losl  his  left  arm  at  the  siege  of  Fontenay.  Having  at  first  refused  amputa- 
tion— his  arm  was  shattered  by  the  shot  of  an  arquebuse — preferring  to  die 
rather  than  to  be  incapacitated  for  fighting,  he  was  at  length  persuaded  by 
his  friends  to  submit  himself  to  the  surgeon's  hands,  and  the  Queen  of  Ka- 
varrc  herself  held  his  arm  during  the  operation.  An  iron  arm  supplied  the 
place  <>f  the  missing  member,  and  gave  its  bearer  the  sobriquet  of  "Bras  de 
Fer;"  the  artificial  limb  served  to  hold  his  horse's  bridle,  and  enabled  the 
gallant  captain  to  engage  in  fresh  battles  with  renewed  ardor.1  Ambroise 
l?are  describes  and  figures  several  varieties  of  artificial  arms  and  legs — the 
former  made  of  iron,  boiled  leather,  or  glued  paper,  and  the  latter  of  wood. 
These,  he  obtained,  lie  says,  from  a  locksmith  of  Paris,  named  "  le  petit  Lor- 
rain,"  and  their  mechanism  was  so  perfect  as  to  enable  the  wearer  to  imitate 
the  natural  movements  of  the  parts  which  had  been  lost,  and  even  to  hold  a 
pen  for  writing.8     Among  the  artificial  legs  is  one  for  "  poor  men,"  which  is 

1  See  Malgaigne's  edition  of  Pare,  already  quoted,  tome  ii.  p.  G17,  note. 

2  Op.  cit.,  tome  ii.  p.  015. 


PROTHETIC   APPARATUS    AND   THE   ADAPTATION   OF   ARTIFICIAL   LIMBS.      607 

in  all  essential  particulars  the  same  as  the  "box-leg,"  which  we  still  often  see 
at  the  present  day.  The  chief  objection  to  the  iron  arm  made  by  "le  petit 
Lorrain"  was  its  weight,  which  was  so  great  that  it  could  only  be  worn  for 
short  periods ;  and  it  is  told  to  the  praise  of  the  Nuremberg  mechanic  who 
about  the  same  time,  or  possibly  earlier,  made  the  iron  hand  worn  by  ( S-oethe's 
hero,  Gotz  von  Berlichingeii,  that  the  artificial  member  supplied  for  that 
gallant  soldier's  use  weighed  but  three  pounds. 

Very  ingenious  substitutes  for  lost  limbs  are  available  at  the  present  day, 
and  the  mechanic's  art  is  enabled  to  supply  any  deficiency,  from  the  Ins-  of  a 
single  finger  to  that  caused  by  an  amputation  at  even  the  hip  or  shoulder-joint. 

Prothetic  Apparatus  for  the  Upper  Extremity. — The  simplest  form  of 
artificial  arm  for  an  amputation  above  the  elbow,  consists  of  a  neatly-fitting 
sheath  of  leather  terminating  in  a  block  to  which  can  be  attached  a  hook,  a 
knife,  a  fork,  or,  for  show  purposes,  a  wooden  hand  ;  by  curving  the  arm,  as 
suggested  by  Mr.  Bigg,  at  a  point  corresponding  to  the  missing  elbow,  the 
appearance  of  the  artificial  limb  is  very  much  improved,  while  a  joint,  allow- 
ing of  motion  at  the  elbow  by  means  of  a  concealed  wheel  and  ratchet,  moved 
by  the  other  hand,  makes  the  limb  still  more  useful.  In  cases  of  amputation 
at  the  shoulder-joint,  apposition  is  effected  by  means  of  a  leather  cap  covering 
the  shoulder  and  side  of  the  chest.  For  stumps  below  the  elbow,  a  similar 
apparatus  is  applicable,  of  course  without  the  joint.  Such  a  contrivance  as 
that  above  described  is  usually  all  that  patients  ask  for,  and  I  have  known 
great  use  made  of  even  a  simple  sheath  and  fixed  hook :  indeed,  the  large 
majority  of  men  who  lose  an  arm,  do  not  employ  any  artificial  substitute, 
finding  that,  with  a  little  practice,  one  arm  can  reasonably  do  the  work 
of  two. 

For  special  cases,  however,  something  more  is  required.  The  natural 
motions  of  the  wrist  can  be  imitated ;  a  spring  placed  within  the  artificial 
thumb  allows  a  pen  to  be  held  between  that  and  the  forefinger,  and  thus 
enables  the  patient  to  write;  and  finally  an  ingenious  arrangement  of  lever-, 
springs,  or  pulleys,  concealed  in  the  hand,  permits  the  fingers  to  be  moved 
as  in  the  natural  member.  With  M.  Bechard's  artificial  arm,  two  hands  are 
furnished — one  naked  and  one  gloved — to  replace  each  other  according  to  the 
needs  of  the  occasion.     Among  the  most  ingenious  forms  of  artificial  arm 

Fisr.  155. 


Artificial  arm. 


which  have  been  devised,  may  be  specially  mentioned,  besides  that  of  Bechard, 
those  of  Van  Petersen  and  Charriere,  and,  among  less  expensive  appliances, 
that  invented  by  M.  de  Beaufort,  which  has  been  further  usefully  modified 
by  Mr.  Heather  Bigg.  The  power,  in  cases  of  amputation  above  the  elbow, 
is  derived  from  the  opposite  arm,  through  the  medium  of  cords  of  catgut, 
but  in  Bigg's  apparatus  for  amputation  below  the  elbow,  is  derived  from  the 


008 


AMPUTATIONS. 


mutilated  arm  itself.     The  accompanying  illustrations  (Figs.  154-157)  show 
the  mechanism  of  the  artificial  arm  and  hand  manufactured  by  Mr.  Kolbe,  of 


Fie.  158. 


Artificial  hand. 


Fig.  157. 


Mechanism  of  artificial  hand  exposed. 


India-rubber  hand. 


Fiff.  159. 


this  city  (Philadelphia),  which  are  among  the  best  in  the  American  market. 
Fig.  158  shows  an  ingenious  artificial  hand,  made  of  India-rubber  by  Mr. 
Marks,  of  New  York. 

Prothetic  Apparatus  for  the  Lower  Extremity. — Artificial  legs  are  of 
much  more  value  in  a  practical  point  of  view  than  artificial  arms,  which  are 
indeed  not  seldom  voluntarily  laid  aside  by  those  who  possess  them,  or  are 
only  worn  upon  special  occasions.  The  simplest  form  of  artifi- 
cial leg  is  the  "  box-leg"  (Fig.  159),  adapted  for  the  reception 
of  the  bent  knee  after  amputation  at  what  was  formerly  called 
the  "  point  of  election,"  a  short  distance  below  the  tubercle  of 
the  tibia.  This  apparatus  is,  as  already  remarked,  almost 
identical  with  the  "  poor-man's  leg,"  described  by  Ambroise 
Pare  more  than  three  centuries  ago.  An  improvement  over 
this  is  the  "-bucket"  or  "socket-leg,"  which  is  adapted  to  the 
extended  limb,  and  is  so  arranged  as  to  prevent  pressure  upon 
the  cicatrix  at  the  end  of  the  stump.  For  amputation  below  the 
knee,  a  socket  closely  fitting  the  limb  is  employed,  with  a 
leather  thigh-band  or  lateral  straps,  or,  which  is  much  better, 
a  limb  with  two  buckets,  one  for  the  leg  and  the  other  sur- 
rounding the  thigh,  thus  completely  taking  ofi'  the  weight  from 
the  end  of  the  stump,  and,  at  the  same  time,  greatly  facilitating 
the  act  of  throwing  the  leg  forward  in  walking.  For  amputa- 
tions above  the  knee,  the  bucket  should  be  so  arranged  as  to 
transfer  all  pressure  to  the  tuberosity  of  the  ischium.  Care 
must  also  be  taken  so  to  adjust  the  artificial  limb  that  the 
centre  of  gravity  of  the  bod}7  shall  fall  within  its  base,  as  in  the  normal  con- 

~~ikle 

.  of 
._  devised 

a  limb  for  use  after  amputation  at  the  hipjoint,  in  which  motion  is  permitted 
at  points  corresponding  to  all  three  articulations  of  the  lower  extremity. 

Among  the  more  elaborate  forms  of  artificial  leg  which  have  acquired 
popularity  in  modem  times,  may  be  mentioned  the  "Anglesey  leg"  (so  called 

—  at 
ila- 

&    •■- li 

affords,  has  always  been  a  favorite  in  this  country.     Fig.  100  shows  the  me- 
chanism of  a  leg  made  by  Mr.  Blanck,  of  Philadelphia,  which  closely  resem- 


Box-leg. 


PROTHETIC   APPARATUS   AND   THE   ADAPTATION   OF   ARTIFICIAL   LIMBS.       GOO 

bles  the  "Palmer  leg,"  and  is  really  a  very  useful  and  satisfactory  piece  of 
mechanism.  Various  ingenious  devices  have  been  adapted  in  <  >r<  ler  to  provi<  Le 
lateral  and  rotatory,  as  well  as  antero-posterior  motion  at  the  ankle-joint,  those 
specially  worthy  of  mention  being  found  in  the  forms  of  apparatus  made 
respectively  by  Dr.  Bly,  of  Rochester,  Mr.  Marks,  of  New  York,  and  Mr. 
Kolbe,  of  Philadelphia.     The  peculiarity  of  the  "Bly  leg"  (Figs.  161,  162), 


Fig.  160. 


Fig.  161. 


Fig.  162. 


Mechanism   of  ankle   in  the  "  Bly"  leg. 
B,  glass    ball  ;  C,  tendons:  G,  leg  piece. 


The  "  Bly"  leg.  A,  spring  for  toes  ;  B,  glass Tjall for  lateral  motion 
at  ankle;  C,  artificial  tendon;  D,  attachment  for  knee  spring;  li,km-e 
spring;  F,  knee  tendon  ;  H,  cord  to  limit  motion  of  knee;  S,  ankle 
springs  ;  N,  nnt  to  regulate  springs. 


which  is  now  manufactured  by  Mr.  Fuller,  of  Rochester,  N".  Y.,  is  that  the 
a"hkle-joint  is  formed  by  a  ball  of  polished  glass  playing  in  a  vulcanite  socket, 
motion  being  afforded  by  means  of  India-rubber  "compression"  springs,  with 
cords  which  represent  the  natural  tendons.  The  "Marks  leg" (Fig.  103)  dis- 
penses with  a  joint  altogether,  the  necessary  motion  in  different  directions 
being  provided  for  by  the  flexibility  and  elasticity  of  the  foot  itself,  which  is 
made  of  India-rubber  surrounding  a  smaller  wooden  frame.  The  "Kolbe 
leg"  (Figs.  164,  165)  affords  lateral  motion  at  the  ankle  by  giving  the  steel 
ankle  bolt  a  globular  enlargement  at  its  centre,  corresponding  to  hemispheri- 
cal depressions  in  both  foot" and  leg  pieces,  the  ends  of  the  bolt  passing  loosely 
through  holes  in  the  metal  side  straps,  and  being  furnished  with  India-rubber 
supports  so  as  to  permit  the  necessary  movements. 
vol.  I. — 39 


G10 


AMPUTATIONS. 


The  use  of  metallic  springs,  in  artificial  limbs  for  the  lower  extremity,  is 
now  very  generally  abandoned  in  favor  of  those  made  from  India-rubber. 


Far.  163. 


India-rubber  foot  of  the  "  Marks"  leg. 


Air.    Heather  Bigg,  of  London,  has  modified  the  mechanism  of  the  "  Bly 
leg,"  by' employing  but  a  single  tendon,  which  passes  through  the  axis  of  the 


Fig.  164. 


Fig.  165. 


The  "  Kolhe"  \eg.  A  H,  joint  of  toes  ;  B,  ankle;  C, 
knee  ;  F  F,  artificial  tibialis  amicus  ;  G  G,  artificial  quad- 
riceps femoris  ;  E  I  and  I)  K,  artificial  gastrocnemius  and 
eoleus. 


Mechanism  of  ankle  in  the  "  Kolbe"  leg. 


joint,  while  retaining  the  ball  and  socket  character  of  the  articulation.  No 
artificial  leg  should  bo  applied  until  the  stump  is  thoroughly  healed  and  solid, 
three  months  being  the  minimum  interval  which  should  be  allowed  to  elapse 
after  the  amputation. 


Mortality  and  Causes  of  Death  after  Amputations. 

The  rate  of  mortality  after  amputation  has  always  been  a  favorite  subject 
of  study  with  workers  in  surgical  statistics,  and,  as  already  pointed  out,  al- 


MORTALITY  AND  CAUSES  OF  DEATH  AFTER  AMPUTATIONS.        Gil 

most  every  inventor  of  a  new  method  of  operating,  or  new  mode  of  dressing 
from  the  days  of  Benjamin  Bell1  to  our  own,  has  adduced  figures  to  prove 
that  his  plan  is  better  than  that  of  his  predecessors.  But  the  circumstances 
of  cases  are  so  different,  that  the  statistics  thus  furnished  have,  so  far,  been 
of  very  little  value.  If  it  could  be  shown  that  by  any  special  form  of  opera- 
tion— -as,  for  instance,  Teale's — -or  under  any  special  mode  of  dressing — as, 
for  instance,  Lister's  or  Guerin's — a  large  number,  say  a  hundred,  con- 
secutive cases  of  (1)  primary  amputation,  (2)  in  the  lower  third  of  the 
thigh,  (3)  for  compound  fracture  by  railway  injury,  (4)  in  healthy  young  men 
between  20  and  25  years  of  age,  (5)  operated  on  in  any  particular  hospital, 
and  (6)  with  a  certain,  definite  degree  of  care  exercised  in  the  constitutional 
and  hygienic  after-treatment,  furnished  decidedly  better  results  than  the  same 
number  of  consecutive  cases  of  precisely  the  same  character,  and  under  pre- 
cisely the  same  circumstances,  except  as  regards  the  form  of  operation  or 
mode  of  dressing  ;  such  a  demonstration  would  afford  a  powerful  argument 
in  favor  of  the  particular  plan  recommended.  But  such  a  demonstration  has 
not  been  as  yet  furnished,  nor,  indeed,  as  far  as  I  know,  even  attempted,  by 
the  advocates  of  any  of  the  methods  which  have  been  referred  to ;  and  a  mo- 
ment's reflection  will  show  how  useless  it  must  be  to  compare  tables  of  cases 
which  are  really  not  comparable,  either  in  regard  to  the  age  and  general  con- 
dition of  the  patients,  the  nature  of  the  lesions  requiring  operation,  the  hy- 
gienic surroundings,  the  care  given  to  after-treatment,  or  other  particulars. 
Nor  can  the  practice  of  one  surgeon,  taken  as  a  whole,  be  fairly  compared 
with  that  of  another;  for  they  may  operate  under  very  different  circum- 
stances: one  in  a  richly  endowed  and  well-ordered  hospital,  the  other  in  a  par- 
simoniously conducted  almshouse;  one  chiefly  upon  children,  the  other  almost 
exclusively  upon  adults;  one  principally  in  cases  of  chronic  joint-disease,  the 
other  in  cases  of  very  severe  and  complicated  injuries.  Again,  one  surgeon 
advises  and  practises  the  operation  of  joint-excision,  and  only  amputates  in 
the  worst  cases,  while  his  colleague  amputates  in  all  cases,  and  of  course  has 
better  statistics. 

While,  however,  I  would  deprecate  any  attempt  to  decide  the  question  of 
the  best  mode  of  operating,  or  of  dressing  stumps,  by  any  figures  now  avail- 
able for  the  purpose,  I  am  far  from  undervaluing  the  importance  of  statistical 
investigation,  in  winch  indeed  I  have  myself  done  a  good  deal  of  work. 
Certain  points  in  reference  to  the  results  of  amputations  can  only  be  (and,  I 
think  I  may  say,  have  been)  established  by  statistical  inquiry,  such  as  the 
comparative  risks  of  primary  and  secondary  operation,  of  operations  for 
injury  as  compared  with  those  for  disease,  etc.  But  before  giving  the  figures 
which  I  have  collected  in  reference  to  these  questions,  I  beg  to  submit  the 
accompanying  Table,  containing  the  record  of  the  first  one  hundred  con- 
secutive, single,  major  amputations  which  I  have  performed,  ipsis  m/mibus, 
during  the  last  nineteen  years,  taken  from  my  note  books.  My  experience 
in  double  amputations  has  already  been  given  (page  592).  I  have,  besides, 
done  seventeen  partial  amputations  of  the  hand  or  foot,  all  of  which  have 
ended  in  recovery ;  this  is  exclusive  of  finger  and  toe  amputations,  of  which 
I  have  kept  no  record. 

1  Benjamin  Bell,  after  deploring  the  large  mortality  which  had  hefore  his  time  attended  ampu- 
tation, declared  :  "  In  the  present  improved  state  of  the  operation,"  that  is,  with  the  triple  inci- 
sion, of  which  he  considered  himself  the  inventor,  "  I  do  not  imagine  that  one  death  will  happen 
in  twenty  cases  ;  even  including  the  general  run  of  hospital  practice  :  and  in  private  practice, 
where  due  attention  can  he  more  certainly  bestowed  upon  the  various  circumstances  of  the  ope- 
ration, the  proportion  of  deaths  will  be  much  less."  (System  of  Surgery,  Seventh  edition,  vol. 
vii.  p.  254.  Edinburgh,  1801.)  It  is  hardly  necessary  to  add  that  these  glowing  anticipations 
have  not  as  yet  been  realized. 


612 


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MORTALITY  AND  CAUSES  OF  DEATH  AFTER  AMPUTATIONS.        617 

The  mortality  after  amputation  has  been  steadily  diminishing  since  the 
early  days  of  our  art,  as  a  result  no  doubt  of  the  use  of  anaesthesia,  the  liga- 
ture, simple  dressings,  and  other  improvements  in  operative  surgery  in  gene- 
ral. From  a  death-rate  of  two  in  three,  which  was  considered  a  favorable 
exhibit  by  the  pioneers  in  this  operation,1  the  mortality,  even  in  city  hospitals 
receiving  a  fair  share  of  accident-cases,  has  fallen  to  one  in  three  or  four;2 
and  when  we  consider  that  a  large  proportion  of  our  operations  are  now  done 
for  injuries  of  the  gravest  character,  such  as  were  simply  not  known  in  the 
days  of  our  ancestors,  it  will  be  seen  that  the  improvement  has  been  still 
more  marked.  And  while  it,  of  course,  cannot  be  denied  that  the  death-rate 
of  the  operation  is  still  a  very  high  one,  it  will  be  found,  by  an  analysis  of 
the  causes  of  death  after  amputation,  that  most  cases  which  terminate  fatally, 
do  so  in  consequence  of  circumstances  totally  unconnected,  if  not  with  the 
operation,  at  least  with  the  particular  form  of  the  operation,  and  with  the 
special  mode  in  which  the  after-treatment  is  conducted. 

Thus,  taking  my  own  Table  of  one  hundred  cases,  the  deaths  are  twenty-eight; 
rather  less  than  the  average  of  hospital  practice,  but  still  a  large  number.  But  upon 
looking  further,  we  find  that  six  patients  died  shortly  after  the  operation,3  as  a  direct 
result  of  their  injuries,  and  that  these  six  cases  included  one  amputation  at  the  hip, 
one  at  the  shoulder,  and  two  high  up  in  the  thigh.  Four  cases  died  in  from  two  to 
twenty  hours,  from  the  shock  of  the  operation,  these  four  including  one  hip  and  one 
shoulder-joint  amputation,  and  one  high  up  in  the  thigh  ;  two  of  the  four  were  more- 
over intermediate  operations,  which  are  well  known  to  be  especially  apt  to  prove  fatal. 
Three  deaths  occurred  from  secondary  hemorrhage  ;  one  of  these  was  after  amputation 
of  the  forearm  by  the  double  flap  method,  the  bleeding  coming  from  the  interosseal 
artery  ;  the  brachial  was  ligated,  but  gangrene  followed,  and  hemorrhage  recurred  and 
ended  fatally  eight  days  afterwards.  In  a  second  case,  one  of  amputation  of  the  arm, 
death  occurred  on  the  third  day  from  hemorrhage  from  the  brachial  artery  which  had 
been  secured  by  acupressure,  a  mode  of  treatment  which,  under  the  fascination  of  Sir 
James  Y.  Simpson's  eloquent  writings,  I  was  then  using.  The  third  case  was  one  of 
thigh  amputation  for  acute  destructive  inflammation  of  the  knee,  resulting  from  syphilis 
in  its  worst  form,  such  as  we  seldom  witness  at  the  present  day  ;  the  ligatures  had  come 
away  safely,  and  rather  early,  and  the  patient  had  been  out  of  bed  for  about  a  week, 
when  bleeding  from  the  femoral  artery  occurred  on  the  28th  day,  and  death  followed 
in  a  few  hours.  Two  deaths  were  from  tetanus  (existing,  in  one  case,  before  the  opera- 
tion), two  from  delirium  tremens,  and  one  from  acute  mania.  Eighteen  of  the  twenty- 
eight  deaths  in  my  Table  are  thus  accounted  for,  and  of  the  remaining  ten,  six  are  put 
down  as  from  exhaustion,  and  four  as  from  pyaemia.  Of  the  six  patients  who  died  from 
exhaustion,  three  were  over  50  years  of  age,  and  all  over  35  ;  five  cases  proved  fatal  in 
from  four  to  six  days  (three  thigh  and  two  leg  amputations),  and  one,  a  forearm-ampu- 
tation which  had  been  complicated  by  secondary  hemorrhage,  on  the  23d  day :  this 
death  might  have  been  attributed  to  pyaemia,  or  other  form  of  septic  poisoning,  but  that 
a  careful  autopsy  failed  to  reveal  any  lesion  significant  of  such  a  condition,  while  it 
did  reveal  advanced  visceral  disease  of  the  heart,  liver,  and  kidneys.  All  of  the  six 
patients  were  persons  in  feeble  health,  and  five  of  them  obviously  unfavorable  subjects 
for  any  operation.  The  first  of  the  four  deaths  from  pycemia  occurred  on  February  2, 
1869,  and  the  last  on  February  2,  1871,  the  two  others  having  occurred  on  February  3, 
and  February  7,  1870.  Thus,  for  more  than  ten  years,  I  have  not  lost  a  case  of  ampu- 
tation from  pyaemia.     These  four  deaths  all  took  place  in  the  same  ward  of  the  Epis- 

1  Benjamin  Bell  says:  "  Before  the  invention  of  the  tottrniquet,  this  operation  [amputation] 
was  attended  with  so  much  hazard,  that  few  surgeons  ventured  to  perform  it :  nay,  long  after  the 
introduction  of  this  instrument,  the  danger  attending  it  was  so  great,  that  more  than  one-half 
perished  of  all  who  had  resolution  to  submit  to  it."  (Op.  cit.,  vol.  vii.  p.  254.) 

2  I  am,  of  course,  aware  that  statistics  giving  a  much  smaller  death-rate  have  been  published 
by  various  hospitals  ;  but  on  examining  these  cases  in  detail  it  will  generally  be  found  that  they 
embrace  a  small  proportion  of  amputations  for  injury,  and  a  large  proportion  of  amputations  for 
disease. 

8  One  in  2  hours,  one  in  7  hours,  one  in  8  hours,  one  in  18  hours,  one  on  2d  day,  one  on  3d  day. 


618 


AMPUTATIONS. 


copal  Hospital,  and  from  these  limitations  of  time  and  space,  and  from  the  fact  that  I 
dressed  stumps  then  precisely  as  I  did  before  and  have  done  since,  I  am  disposed  to 
attribute  them  to  local  and  climatic  rather  than  to  any  other  causes. 

Table  showing  Causes  of  Death  in  Twenty-eight  Fatal  Cases  of 
Major  Amputation. 


Direct  result  of  injury 

hock 
Secondary  hemorrhage 
Tetanus   . 
Delirium  tremens     . 


Acute  mania 
Exhaustion 
Pyaemia    . 


Total 


1 
6 

4 

28> 


Deducting  six  deaths  from  the  direct  result  of  injury,  and  three  from  delirium  tre- 
mens and  acute  mania — which  have  certainly  no  connection  with  the  operation  per  se — 
the  mortality  would  be  reduced  to  a  little  over  20  per  cent.,  or  one  in  five.  My  first  50 
cases  gave  18  deaths  (including  all  that  have  occurred  from  pyaemia),  or,  making  the 
corresponding  deductions,  14  out  of  46,  a  mortality  of  30  per  cent.  ;  while  my  second 
50  cases  gave  but  10  deaths,  or,  with  the  corresponding  deductions,  5  out  of  45,  a  mor- 
tality of  only  11  per  cent. 

The  mortality  after  amputation  is  influenced  by  various  circumstances 
which  are  quite  independent  of  the  skill  of  the  operator,  the  most  important 
being  the  age,  constitutional  condition,  and  sex  of  the  patient,  his  hygienic  sur- 
roundings before  and  after  the  operation,  the  nature  of  the  lesion  for  which 
amputation  is  performed,  the  period  of  operation,  and  the  part  of  the  body  in- 
volved. A  few  remarks  upon  each  of  these  points  will  conclude  what  I  have 
to  say  as  to  the  causes  of  death  after  amputation. 

Age  of  Patient. — Amputations  in  children  are  usually  successful.  The 
remarkable  case  of  synchronous  amputation  of  the  hip  and  leg,  which  I  have 
recorded  on  page  591,  would  not  have  ended  in  recovery  had  the  patient  been 
an  adult.  Statistics  showing  the  effect  of  age  in  determining  the  results  of 
amputations  have  been  collected  by  several  writers,  among  whom  I  may  par- 
ticularly mention  M.  Malgaigne,  of  Paris,  the  late  Mr.  Callender,  Mr.  Holmes 
and  Mr.  Golding-Bird,  of  London,  Dr.  Gorman,  of  Boston,  and  Dr.  Morton, 
of  Philadelphia.  The  last-mentioned  surgeon,2  from  an  analysis  of  982  cases 
of  amputation  treated  in  the  Pennsylvania  Hospital  during  50  years,  from 
1830  to  1879,  gives  the  following  Table  showing  the  figures  bearing  upon  this 
point: — 

Table  showing  the  effect  of  Age  on  the  Results  of  Amputation  at  the 

Pennsylvania  Hospital. 


Cured. 

Died. 

Total. 

Mortality 
per  cent. 

From    1  to  10  years,  there  were      .... 

"     10  "  20       """...         . 

"     20  "  30       """... 

"     30  "  40       """...         . 

"     40  "  50       " 

"     50  "  GO       """... 
Upwards  of  60       """.... 

70 

218 

220 

1323 

63 

24 

10 

11 
40 
75 
61 
36 
14 
8 

81 

258 

295 

193 

99 

38 

18 

13+ 
15+ 
25+ 
31+ 
36+ 
36+ 
44+ 

Total  number  of  cases         .... 

737 

245 

982 

25— 

'  I  have  not  included  among  tin-  fatal  eases  that  of  a  woman  who,  two  weeks  after  her  stump 
had  completely  healed,  aborted  of  a  six  months'  child,  and  subsequently  died,  after  the  opening 
(by  another  surgeon)  of  a  pelvic  abscess. 

2  Surgery  of  the  Pennsylvania  Hospital,  etc.,  p.  33.  By  Thomas  G.  Morton,  M.D.,  and  William 
Hunt,  M.D.,  Surgeons  to  the  Hospital.     Philadelphia,  1880. 

3  Clerical  error  in  original  Table  corrected. 


MORTALITY    AND    CAUSES    OF   DEATH    AFTER   AMPUTATIONS. 


619 


Mr.  Golding-Bird1  has  in  a  similar  manner  analyzed  the  results  of  559  am- 
putations practised  at  Guy's  Hospital  during  15  years,  from  I860  to  1874  (in- 
clusive), and  shows  that  they  were  as  follows: — 

Table  showing  the  effect  of  Age  on  the  Results  of  Amputation  at 

Guy's  Hospital. 


Cured. 

Died. 

Total. 

Mortality 
per  cent. 

Patients  less  than  20  years  old         .... 
"         from  20  to  40         "               .... 
"        oyer  40  years  old        ..... 

121 

145 

95 

33 

78 
87 

154 
223 
182 

21.4 
34.9 

47.8 

Total  number  of  cases        .... 

361 

198 

559 

35.4 

Dr.  Gorman's2  statistics,  derived  from  the  practice  of  the  Boston  City  Hos- 
pital, give  the  results  of  285  terminated  cases  of  amputation  in  persons  whose 
age  was  ascertained.     The  results  are  shown  in  the  following  Table : — 

Table  showing  the  effect  of  Age  on  the  Results  of  Amputation  in  the 

Boston  City  Hospital. 


Cured. 

Died. 

Total. 

Mortality 
per  cent. 

Patients  less  than  20  years  old         .... 
"         from  20  to  40         "               .... 
"         over  40  years  old        ..... 

50 
94 
40 

22 
47 
32 

72 
141 

72 

30.5 
33.3 
44.7 

Total  number  of  cases        .... 

184 

101 

285 

35.4 

Mr.  Holmes's  statistics3  are  derived  from  the  practice  of  St.  George's  Hos- 
pital, and  embrace  500  cases.  I  have  re-arranged  his  table  so  as  to  make  it 
correspond  in  form  with  those  which  I  have  already  given. 

Table  showing  Effect  of  Age  on  Results  of  Amputation  at  St.  George's 

Hospital. 


Cured. 

Died. 

Total. 

Mortality 
per  cent. 

Patients  less  than  5  years  old     ..... 

4 

1 

5 

20.0 

"         between    5  and  10  years  old 

18 

2 

20 

10.0 

"              "         10   "     15            " 

33 

4 

37 

10.6 

«               u         15    «     20            " 

53 

15 

68 

22.6 

"              "        20    "     30           " 

90 

30 

120 

25.0 

"              "         30    "     40           " 

57 

38 

95 

40.0 

"              "        40    "     50           " 

46 

29 

75 

31.3 

«              (i         50    tt     60            tt 

25 

26 

51 

50.9 

u              u         go    "     70            " 

12 

11 

23 

47.9 

"         over  70  years  old 

4 

2 

6 

33.3 

Total  number  of  cases   ..... 

342 

158 

500 

31.6 

Mr.  Holmes  particularly  points  out,  in  regard  to  these  cases,  that  two  of  the 
three  deaths  in  patients  less  than  10  years  of  age  were  totally  unconnected 

1  Guy's  Hospital  Reports,  3d  s.,  vol.  xxi.  p.  253. 

2  Medical  and  Surgical  Reports,  Second  series,  1877,  p.  291.  Dr.  Gorman's  Tables  embrace  in 
all  299  cases,  but  in  3  cases  the  result  was  not  determined,  and  in  11  more  the  age  of  the  patient 
is  not  given. 

3  St.  George's  Hospital  Reports,  vol.  viii.  p.  269. 


620 


AMPUTATIONS. 


with  the  operation,  and  that,  on  the  other  hand,  the  patients  over  60  years  of 
age  presented  more  than  ordinarily  favorable  cases — four  of  the  amputations 
in  those  over  70  having  been  of  the  forearm,  and  in  those  between  60  and  70 
hardly  any  of  the  amputations  having  been  for  injury  of  the  lower  extremity. 
The  late  Mr.  Callender,  in  1864,  presented  to  the  Royal  Medical  and  Chi- 
rurgical  Society  of  London,1  statistics  of  358  amputations  performed  during 
ten  years  at  St.  Bartholomew's  Hospital.  The  deaths  at  different  ages  in  227 
of  these  cases,  are  shown  in  the  following  Table : — 

Table  showing  effect  of  Age  on  Results  of  Amputation  at  St.  Bartho- 

lomew's  Hospital. 


Cured. 

Died. 

Total. 

Mortality 
per  cent. 

Patients  less  than  10  years  old    . 
;'         between  10  and  20  years  old 
20   "     30         " 
"       30    "     40         " 
"       40   "     50         " 

50   "     60 
"        60   "     70         " 
"        70    "     80         " 

8 
50 
46 
26 
23 
16 
4 
1 

0 
3 

13 
7 

13 
9 
3 
5 

8 
53 
59 
33 
36 
25 
7 
6 

0.0 
5.6 
22.4- 
21.2 
36.1 
36.0 
42.8 
83.3 

Total  number  of  cases   ..... 

174 

53 

227 

23.3 

M.  Malgaigne's  figures2  embrace  560  cases,  of  which  299  terminated  fatally. 

Table  showing  the  Effect  of  Age  on  Results  of  Amputation  in  Parisian 

Hospitals. 


Cured. 

Died. 

Total. 

Mortality 
per  cent. 

Patients  less  than  5  years  old    . 

"          between     5  and  15  years  old 

"               "           15    "     20 

"              "           20   "     35 

"              "           35    "     50 

"              "           50    "     65         " 

"         more  than  65         ...         . 

2 
44 

45 
91 
50 
20 
9 

3 

22 
36 
102 
76 
50 
10 

5 
66 
81 
193 
126 
70 
19 

60.0 
33.3 
44.4 

52.8 
60.3 
71.4 
52.6 

Total  number  of  cases  ..... 

261 

299 

560 

53.3 

My  own  Table  tells  a  similar  tale  of  mortality  increasing  with  advancing 
years ;  the  larger  mortality  between  the  ages  of  20  and  30  than  between  those 
of  30  and  40,  is  explained  by  the  circumstance  that  the  cases  in  the  former 
category  embraced  two  fatal  amputations  at  the  hip-joint,  and  one  fatal  (in- 
termediate) amputation  at  the  shoulder-joint. 


1  Transactions,  vol.  xlvii.  p.  75. 

2  Archives  Gcnerales  de  Medecine,  Mai,  1842,  pp.  59,  61. 


MORTALITY  AND  CAUSES  OF  DEATH  AFTER  AMPUTATIONS. 


621 


Table  showing  Effect  of  Age  in  One  Hundred  Cases  of  Amputation. 


Cured. 

Died. 

Total. 

Mortality 
per  cent. 

Patients  less  than  10  years  old  .... 
"         between  10  and  20  years  old 
"               "        20     "     30          "             .         . 
"               "        30     "     40          "             .         . 
"              "        40     "     50          "             . 
"         more  than             50          " 
"         of  uncertain  age  ;   "adults" 

7 

26 

15 

13 

5 

4 

2 

0 
2 
8 
5 
5 
6 
2 

7 
28 

23 
18 
10 
10 
4 

0.0 
7.1 
34.7 
27.7 
50.0 
60.0 
50.0 

Total  number  of  cases 

72 

28 

100 

28.0 

In  order  to  show  the  correspondence  with  each  other  of  these  statistics 
derived  from  different  sources,  I  have  compiled  the  two  following  tables, 
showing  (1)  the  percentage  of  mortality  at  the  three  periods  of  life:  under 
20  years,  from  20  to  40,  and  over  40— the  classification  adopted  by  Mr. 
Golding-Bird ;  and  (2)  the  percentage  of  mortality  before  and  after  30  years 
of  age — the  division  adopted  by  Mr.  Holmes : — 

Table  showing  Percentage  of  Mortality  at  Different  Ages.1 


Whole 
number 
of  cases. 

Mortality 

below 
20  years, 
per  cent. 

Mortality 
betweeu 
20  and  40, 
per  cent. 

Mortality 

over 
40  years. 
per  cent. 

General 
death-rate, 
per  cent. 

Pennsylvania  Hospital         .... 

Guy's  Hospital    ...... 

St.  George's  Hospital  ..... 

St.  Bartholomew's  Hospital 

Boston  City  Hospital  ..... 

Author's  cases2    ...... 

982 
559 
500 
227 
285 
96 

15.0 

21.4 
16.9 

4.9 
30.5 

5.7 

27.8 
34.9 
31.6 
21.7 
33.3 
31.7 

37.4 

47.8 
43.8 
40.5 
44.7 
55.0 

25.— 

35.4 

31.6 

23.3 

35.4 

27.+ 

Total  number  of  cases 

2649 

16.7 

30.1 

43.4 

29.4 

Table  showing  Percentage  of  Mortality  before  and  after  Thirty  Years 

*       of  Age.3 


Whole 
number 
of  cases. 

Mortality 

below 
30  years, 
per  cent. 

Mortality 

over 
30  years, 
per  cent. 

General 
death-rate, 

per  cent. 

St.  George's  Hospital           ...... 

St.  Bartholomew's  Hospital        ..... 

500 

227 
96 

19.8 
20.8 
13.3 
17.2 

34.2 
42.4 
34.5 
42.1 

25.+ 
31.6 
23.3 
27.+ 

Total  number  of  cases       .... 

1805 

19.2 

37.4 

26.7 

These  Tables,  the  figures  of  which  are  sufficiently  large  to  afford  informa- 
tion of  value,  show,  it  seems  to  me,  very  conclusively,  the  influence  of  age 
on  the  results  of  amputations  ;  they  show  (1)  that  in  persons  less  than  twenty 
years  old,  the  operation  is  a  comparatively  safe  one,  but  that  in  patients  from 
twenty  to  forty,  it  is  nearly  twice,  and  in  those  over  forty,  not  far  from  three 

1  M.  Malgaigne's  statistics  do  not  give  the  ages  in  such  a  way  as  to  be  included  in  this  Table. 

2  Age  in  4  cases  not  stated. 

3  M.  Malgaigne's,  Mr.  Golding-Bird's,  and  Dr.  Gorman's  Tables  do  not  show  how  many  patients 
were  under  and  how  many  over  thirty  years  of  age. 

4  Age  in  4  cases  not  stated. 


622  AMPUTATIONS. 

times  as  apt  to  be  followed  by  death  as  during  the  earlier  period  ;  and  (2)  that 
in  persons  more  than  thirty  years  of  age,  amputation  is  almost  twice  as  fatal 
as  in  those  who  are  younger. 

Constitutional  Condition. — The  influence  of  pre-existing  constitutional 
affections  on  the  results  of  injuries  and  surgical  operations  in  general,  has 
been  forcibly  set  forth  by  Prof.  Verneuil  in  a  preceding  article  of  the  present 
volume  (page  307),  and  the  same  lesson  has  been  taught  by  Dr.  Brinton  in 
his  remarks  on  Operative  Surgery  in  General  (page  463).  It  remains  for  me 
therefore,  in  this  place,  merely  to  adduce  certain  particular  illustrations  of 
the  truth  of  these  doctrines  as  applied  to  amputations.  Mr.  Birkett1  has 
recorded  the  results  of  167  single  amputations,  mostly  performed  by  himself 
in  the  wards  of  Guy's  Hospital.  Of  the  whole  number  of  cases,  53  proved 
fatal,  10  dying  from  the  immediate  effects  of  the  injuries  for  which  the  ope- 
ration was  performed,  and  22  (or  more  than  half  of  the  remainder)  being 
proved  by  post-mortem  examination  to  have  been  the  subjects  of  chronic  disease 
of  the  viscera,  while  in  fifteen  more  the  patients'  powers  of  nutrition  were 
evidently  impaired  before  the  operation.  Mr.  Holmes,  in  his  two  papers,2  has 
recorded  500  cases,  of  which  148  proved  fatal :  in  33  of  these,  the  patients' 
death  was  inevitable,  resulting  from  causes  unconnected  with  the  operation ; 
and  in  57  more,  death,  though  probably  not  inevitable,  was  mainly  due  to 
visceral  disease  or  other  morbid  conditions  existing  prior  to  the  amputation. 
Mr.  Bryant's  Table  of  300  cases3  shows  that  well-marked  visceral  disease  was 
the  cause  of  death  in  13  per  cent,  of  all  fatal  cases,  and  in  Mr.  Calender's 
Tables  of  358  cases,4  the  mortality  from  the  same  cause  was  over  16  per  cent., 
while  Dr  Chevers,  in  his  Inquiry  into  the  causes  of  death  after  injuries  and 
surgical  operations  (not  exclusively  amputations),5  found  that  of  153  fatal 
cases,  the  kidneys  were  markedly  diseased  in  at  least  72,  the  liver  and  spleen 
also  being  often  affected,  and  that  "in  a  rather  large  proportion  of  these  cases, 
the  disease  of  the  liver,  spleen,  and  kidneys  had  evidently  existed  for  a  very 
considerable  time  previous  to  the  patient's  receiving  the  wounds  or  injuries 
which  became  the  apparent  primary  causes  of  death." 

Sex. — The  influence  of  visceral  disease  upon  the  mortality  of  amputations, 
is,  of  course,  largely  concerned  in  rendering  the  operation  more  fatal  among 
adults  than  among  children — healthy  viscera  being  the  rule  in  childhood  ; 
and  the  same  influence  is  no  doubt  shown  in  the  slightly  greater  risk  in  per- 
sons of  the  male  than  in  those  of  the  female  sex — men,  at  the  period  of  life 
at  which  most  amputations  are  performed,  being,  from  their  habits  and  modes 
of  living,  probably  more  apt  to  be  the  subjects  of  visceral  disease  than  women 
of  the  same  age.  This  point  may  be  illustrated  by  Dr.  Steele's  Tables  of  507 
eases  of  amputation  in  Guy's  Hospital  during  the  fifteen  years  from  1854  to 
1868. 6  The  mortality  among  males  was  37.7  per  cent.,  but  among  females 
only  21.5  per  cent.  In  Malgaigne's  560  cases7  of  major  amputation  derived 
from  various  French  hospitals,  the  male  mortality  was  over  55  per  cent., 
the  female  less  than  47  per  cent. ;  and  in  Trelat's  1144  cases,8  also  derived 

1  Guy's  Hospital  Reports,  3d  s.,  vol.  xv.  p.  502. 

2  St.  George's  Hospital  Reports,  vol.  i.  p.  291,  and  vol.  viii.  p.  269. 
1  Medico-Chirurgioal  Transactions,  vol.  xlii.  p.  t>7. 

4  Ibid.;  vol.  xlvii.  p.  75. 

5  Guy's  Hospital  Reports,  2d  s.  vol.  i.  p.  78. 

6  Guy's  Hospital  Reports,  3d  s.  vol.  xv.  p.  (500.  I  hare  not  utilized  Dr.  Steele's  statistics  as  to 
the  effects  of  age,  because  his  Tables  are  overlapped  by  those  of  Mr.  Golding-Bird,  which  are 
somewhat  larger. 

7  Archives  Generates  <le  Medecine,  Mai,  1K42,  p.  57. 

9  Bulletin  de  1' Academic  Iinperiale  de  Medecine,  tome  xxvii.  p.  591. 


MORTALITY  AND  CAUSES  OF  DEATH  AFTER  AMPUTATIONS. 


623 


from  French  hospitals  at  a  later  period,  the  male  mortality  was  48.2  per 
cent.,  and  the  female  but  35.5  per  cent.  The  same  thing  is  shown,  on  a 
smaller  scale,  by  my  own  Table — the  mortality  in  the  male  sex  having  been 
28.5  per  cent.,  and  in  the  female  sex  only  22.2  per  cent.  But  in  St.  Bartholo- 
mew's Hospital,1  and  in  the  Pennsylvania  Hospital2  (where,  however,  compa- 
ratively few  women  have  submitted  to  amputation),  the  mortality  bus  been 
larger  among  them  than  in  persons  of  the  male  sex. 

Table  showing  the  relative  Mortality  after  Amputation  in  the  two  Sexes. 


Authority. 

Whole 
.No.  of 
cases. 

Males. 

Females. 

Whole  number. 

Cured. 

Died. 

Mort. 
per  ct. 

Cured. 

Died. 

Mort. 
per  ct. 

Cured. 

Died. 

Mort. 

per  ct. 

Malgaigne 

Tielat 

Steele 

Calleuder  . 

Morton 

Author 

560 
1144 

507 
227 
982 
100 

200 

470 
252 
134 
704 
65 

245 
438 
153 

37 
231 

26 

55.4- 

48.2 
37.7 
21.6 
24.7 
28.5 

61 
152 

80 
40 
31 

7 

54 
84 
22 
16 
16 
2 

46.9 
35.5 
21.5 

28.5 

34.4- 

22.2 

261 

622 
332 
174 
735 
72 

299 

522 

175 

53 

247 
28 

53.3 

45.6 

34.5 

23.3 

25.— 

28.0 

Total  number  of  cases 

3520 

1825 

1130 

38.2 

371 

194 

34.3 

2196 

1324 

37.6 

Hygienic  Surroundings  of  Patients. — It  is,  of  course,  easy  to  understand 
that  cases  of  amputation,  as  all  other  surgical  cases,  should  result  more 
favorably  when  treated  in  clean  and  well-ventilated  buildings,  and  when  the 
patients  are  carefully  nursed  and  suitably  nourished  after  the  operation,  than 
when  this  is  practised  in  foul  and  close  apartments,  and  the  patients  neglected 
and  perhaps  half  starved  afterwards.  It  was  no  doubt  owing  to  a  positive 
disregard  of  ordinary  hygienic  precautions  that  amputation  was  formerly 
such  a  fatal  operation  in  the  Parisian  Hospitals,  when,  according  to  tne  statis- 
tics of  Malgaigne3  and  Trelat,4  almost  every  other  patient  who  lost  a  limb 
died.  But  more  than  this,  not  only  do  the  surroundings  of  the  patient  at  the 
time  of,  and  after  the  operation,  greatly  influence  the  result,  but  the  circum- 
stances under  which  he  has  been  placed  before  the  operation  have  likewise  a 
very  decided  influence  in  determining  its  favorable  or  unfavorable  issue. 
Some  years  since,  the  late  Sir  J.  Y.  Simpson,  in  his  papers  on  Hospitalism,5  col- 
lected a  large  number  of  statistics,  and  by  them  proved  to  his  own  satisfac- 
tion, if  not  to  that  of  others,  that  the  mortality  after  amputation  in  city  hos- 
pitals was  about  four  times  as  large  as  in  country  practice ;  but  the  fact  is 
that  patients  who  have  lived  in  the  country,  do  better  after  amputations  than 
the  inhabitants  of  cities,  even  in  city  hospitals — so  that  the  question  again 
turns  upon  the  constitutional  condition  of  the  individual  patient,  as  influ- 
enced by  the  circumstances  of  his  past  life,  rather  than  upon  anything  special 
to  the  operation  itself,  or  even  to  the  particular  building  in  which  it  is  per- 
formed. This  point  may  be  illustrated  by  the  figures  given  by  the  late  Mr. 
Callender,6  of  the  results  of  amputations  practised  by  Sir  James  Paget  and 
himself  during  the  years  1861 — 1869:  while  the  whole  number  of  cases 
was  97,  with  a  mortality  of  29.8  per  cent.,  the  operations  on  city  patients 
numbered  68,  with  a  mortality  of  35.3  per  cent.,  whereas  those  on  country 
patients  numbered  29,  with  a  mortality  of  only  17.2  per  cent.     Similarly, 

1  Callender,  loc.  cit.  2  Morton,  loc.  cit. 

3  Archives  Generales  de  MeVlecine,  Avril  et  Mai,  1842. 

4  Legouest,  Chirurgie  d'Armee,  p.  707.     Paris,  1S68. 

5  Works,  vol.  ii.  p.  289.     New  York,  1872. 

8  St.  Bartholomew's  Hospital  Reports,  vol.  v.  p.  249. 


624 


AMPUTATIONS. 


among  507  cases  tabulated  by  Dr.  Steele,1  from  the  records  of  Guy's  Hospital, 
while  the  mortality  of  the  whole  number  was  34.5  per  cent.,  the  death-rate 
among  383  patients  from  London  and  its  suburbs,  was  35.7  per  cent. ;  and 
that  among  124  patients  from  country  districts,  only  30.6  per  cent. 

Table  showing  the  Influence  of  Previous  Residence  on  the  Results  of 

Amputations. 


Whole 
No.  of 
cases. 

Aggregate. 

City  and  suburban 
patients. 

Country  patients. 

Cured. 

Died. 

Mort. 
per  ct. 

Cured. 

Died. 

Mort. 
per  ct. 

Cured. 

Died. 

Mort. 
per  ct. 

St.  Bartholomew's  Hospital  . 
Guy's  Hospital 

97 
507 

68 
332 

29 
175 

29.8 
34.5 

44 

246 

24 

187 

35.3 
35.7 

24 

86 

5 

38 

17.2 
30.6 

Total  number  of  cases 

604 

400 

204 

33.7 

290 

161 

35.6 

110 

43 

28.1 

Closely  connected  with  this  question  of  "hospitalism,"  is  that  of  the  occur- 
rence of  various  forms  of  blood-poisoning,  such  as  erysipelas,  pyaemia,  hospital 
gangrene,  etc.  It  was  shown  by  the  famous  "  discussion  on  pyaemia,"  before  the 
Clinical  Society  of  London,2  that  these,  which  are  often  spoken  of  as  "hospital- 
diseases,"  are  really,  except  as  far  as  it  depends  upon  the  different  constitu- 
tional condition  of  the  patients,  quite  as  common  in  private  practice  as  in  the 
wards  of  hospitals.  And  there  can  be  no  doubt  that,  as  long  ago  pointed 
out  by  Dr.  Chevers,3  in  a  large  proportion  of  cases  which  prove  fatal  from 
internal  inflammations  (under  which  name  our  predecessors  included  what  we 
now  recognize  as  cases  of  pyaemia  and  septicaemia),  previously  existing  visceral 
disease  is  present,  and  not  only  renders- the  patient  peculiarly  susceptible  to 
the  influence  of  these  affections,  but  renders  their  course  much  more  surely 
fatal  than  it  would  be  if  they  occurred  in  a  healthy  subject.4  My  own  ex- 
perience agrees  entirely  with  that  of  Mr.  Holmes,5  that  erysipelas  and  hospital 
gangrene,  or,  as  it  might  better  be  called,  sloughing  phagedena,  are  so  rarely 
the. cause  of  death  after  amputation  that  they  may  practically  be  disregarded. 

Pyaemia,  though  more  often  recognized,  is,  I  have  no  doubt,  really  a  less 
frequent  cause  of  death  after  amputation  than  it  was  when  the  principles  of 
hygiene  were  less  regarded  in  the  construction  and  management  of  both  hos- 
pitals and  private  houses,  than  they  are  at  present.  It  is  still,  however,  a 
very  frequent  cause  of  death.  In  Mr.  Bryant's  statistics,  presented  to  the 
Royal  Medical  and  Chirurgical  Society  of  London,  in  1859,6  the  deaths  from 
pyaemia  after  amputation  at  Guy's  Hospital  were  33  in  number,  a  mortality 
of  43.4  per  cent,  of  fatal  cases,  and  11  per  cent,  of  all  cases  amputated;  but 
in  Dr.  Steele's  table  of  amputations  in  the  same  hospital  from  1861  to  1868,7 
the  mortality  from  the  same  cause  is  registered  as  but  32.7  per  cent,  of  fatal 
cases,  though  12.8  per  cent,  of  all  amputated,  and  in  the  cases  tabulated  in 
the  same  gentleman's  successive  annual  reports  from  1869  to  1878,8  the 
'mortality  from  lliis  source  is  but  23.1  percent,  of  fatal  cases,  and  but  7.6 
per  cent,  of  all  amputated.  In  Mr.  Callender's  358  cases  from  St.  Bartholo- 
mew's I  Iospital,9  there  were  20  deaths  from  pyaemia,  a  mortality  of  27  per 
cent,  of  fatal  cases,  or  5.5  per  cent,  of  all  amputated.     In  Mr.  Holmes's  500 

1  fiuy's  Hospital  Reports,  3d  s.,  vol.  xv.  p.  637. 

2  Transactions,  rol.  vii.  pp.  xlii- cxvii.  3  Loc.  cit.,  p.  91. 

4  Sec  also  Prof.  Verneuil's  remarks  upon  Hepatism  and  Nephrism  in  the  present  volume,  pp. 
326,  327. 

5  St.  George's  Hospital  Reports,  vol.  viii.  p.  296.  6  Transactions,  vol.  xlii.  p.  67. 
7  Guy's  Hospital  Reports,  3d  s.  vol.  xv.  p.  630.                        8  Loc.  cit.,  vols,  xvi-xxiv. 

9  Medico-Chirurgical  Transactions,  vol.  xlvii.  p.  75. 


MORTALITY   AND   CAUSES   OF   DEATH   AFTER   AMPUTATIONS. 


625 


cases,  however,  from  St.  George's  Hospital,1  there  were  76  deaths  from  pye- 
mia (existing  in  one  case  before  the  operation),  a  mortality  of  48.1  per  cent. 
of  fatal  cases,  or  15.2  per  cent,  of  all  amputated.  At  the  Massachusetts 
General  Hospital,2  692  cases  have  given  42  deaths  from  pyaemia  (23.3  per 
cent,  of  fatal  cases,  or  6.4-  percent,  of  all  amputated),  and  at  the  Boston  City 
Hospital,3  296  cases  have  given  23  deaths  from  pysemia  (21.2  per  cent,  of 
fatal  cases,  and  7.7  per  cent,  of  all  amputated).  My  own  table  gives  a  mortality 
from  pysemia  of  but  14.3  per  cent,  of  fatal  cases,  and  but  4  per  cent,  of  all 
amputated. 

Table  showing  the  Mortality  from  Pyemia  after  Amputation. 


Mortality  per  ct.  from 

Total 

Total 

Deaths 
from 

pyaemia 

pyaemia. 

of  fatal 
cases. 

of  total 
cases. 

Guy's  Hospital  (Bryant's  Table) 

300 

76 

33 

43.4 

11.0 

"             "        (18(31-1868)^      .... 

302 

119 

39 

32.7 

12.8 

"             "        (1869-1878)*      .... 

562 

186 

43 

23.1 

7.6 

St.  Bartholomew's  Hospital        .... 

3-38 

74 

20 

27.4- 

5.5 

St.  George's  Hospital          ..... 

500 

158 

76 

48.1 

15.2 

Massachusetts  General  Hospital 

692 

180 

42 

23.3 

6.4- 

Boston  City  Hospital           ..... 

296 

108 

23 

21.2 

7.7 

100 

2S 

4 

14.3 

4.0 

Total  number  of  cases 

3110 

929 

280 

30.1 

9-4- 

The  effects  of  season  and  weather  upon  the  results  of  amputation  have  been 
particularly  investigated  by  M.  Malgaigne,5  and  by  Dr.  Addinell  Ilewson,  of 
Philadelphia,6  whose  conclusions  have  been  already  referred  to  by  Dr.  Brintou 
on  page  461  of  the  present  volume.  It  will  be  sufficient,  therefore,  in  this 
place,  to  mention  that  amputations  performed  while  the  barometer  was  falling 
were  found  to  be  two-and-a-half  times  as  fatal  as  those  performed  while  the 
barometer  was  rising,  and  that  while  the  thermometer  ranged  above  the  mean 
annual  temperature,  the  mortality  was  greater  than  that  when  it  was  below, 
in  the  proportion  of  nearly  seven  to  six.  M.  Malgaigne's  investigations  led 
him  to  believe  that  for  adults,  winter,  and  for  children,  summer,  was  the  most 
favorable  season. 

There  remain  to  be  considered  those  conditions  which  are  peculiar  to  am- 
putation as  distinguished  from  other  operations,  viz.,  the  nature  of  the  lesion, 
the  period  of  amputation,  and  the  part  of  the  body  concerned. 

Nature  of  Lesion. — Amputations  for  disease  are,  as  a  rule,  more  successful 
than  those  for  injur)/;  amputations  for  malignant  disease  or  for  acute  disease 
are  more  fatal  than  those  performed  for  chronic  disease,  such  as  caries,  necr<  »sis, 
or  chronic  suppurative  arthritis.  Amputations  for  deformity,  again,  are  less 
successful  than  those  for  other  non-traumatic  causes.  In  order  to  show  the 
comparative  mortality  of  amputations  for  injury  and  of  those  for  diseasi ,  I 
have  compiled  the  following  table  from  published  statistics  of  French,  Eng- 
lish, and  American  surgeons. 

1  St.  George's  Hospital  Reports,  vols.  i.  and  viii. 

8  Chadwick,  Boston  Medical  and  Surgical  Journal,  vol.  lxxxvi.,  1871.    Supplement,  p.  xix. 

3  Gorman,  loc.  cit.,  pp.  292  et  seq. 

4  Partial  amputations  of  hand  and  amputations  of  fingers  and  toes  omitted. 

6  Loc.  cit.,  p.  63.  6  Pennsylvania  Hospital  Reports,  vol.  ii.  p.  17- 

VOL.  I. — 40 


626 


AMPUTATIONS. 


Table  showing  the  Comparative  Mortality  of  Amputations  for  Injuries 

and  for  Disease. 


Authority. 

Amputations  for 

injury. 

Amputations  for  disease 
and  deformity. 

Total 

amputations. 

Cases.  :  Deaths. 

permease, 

Deaths. 

Mort. 
per  ct. 

Cases. 

Deaths. 

Mort. 
per  ct. 

Malgaigne1        .... 

Trelat2 

Golding-Bird3  .... 
Callender4         .... 
Butlin  and  Macread,)5 
Holmes6    ..... 
Spence7    ..... 
Cliadwick8        .... 
Gorman9  ..... 

Varick10 

Norris  and  Morton" 

Author12  ..... 

182 
470 
334 
130 

10S 
146 

186 
328 
214 

80 
774 

72 

117 

261 

157 
28 
24 
66 
77 

116 
90 
35 

209 
24 

64.2 

55.5 

47.4- 

21.5 

22.2 

45.2 

41.4 

35.3 

42.4- 

43  7 

27.4- 

33.3 

378 

568 

525 

228 

308 

354 

371 

364 

82 

10 

208- 

28 

182 

233 

117 

46 

51 

92 

73 

64 

18 

5 

36 

4 

48.1 

41.4- 

22.2 

20.1 

16.5 

25.9 

19.6 

17.5 

21.9 

50.0 

17.3 

14.2 

560 
1038 
859 
358 
416 
500 
557 
692 
296 
90 
982 
100 

299 
494 
274 

74 

75 
158 
150 
180 
108 

40 
245 

28 

53.3 

47.5 

31.8 

20.6 

18.4- 

31.6 

26.9 

26.4- 

36.4 

44.4 

25.— 

28.0 

Totals 

3024 

1204 

39.8 

3424 

921 

26.8 

6448 

2125 

32.9 

Xot  only  is  the  mortality  less  after  amputation  when  practised  for  disease, 
than  when  practised  for  injury,  in  the  proportion,  as  shown  by  the  preceding 
table,  of  about  two  in  three,  but,  as  already  remarked,  the  result  of  the  ope- 
ration is  more  favorable  in  cases  of  chronic  bone  or  joint  disease — caries, 
necrosis,  etc. — than  in  cases  of  acute  disease,  of  malignant  disease,  or  of 
simple  deformity.  The  mortality  of  amputations  for  expediency  (including 
both  those  for  deformity  and  those  for  tumor),  has  been  particularly  investi- 
gated by  Mr.  Bryant  and  Mr.  Golding-Bird,  at  Guy's  Hospital,  and  their 
combined  statistics13  show  that  the  death-rate  in  this  class  of  cases  wras  26.8 
per  cent.,  as  compared  with  a  death-rate  of  21.1  per  cent,  in  those  of  chronic 
disease.  Among  my  own  28  cases  of  amputation  for  disease,  the  only  ones 
which  proved  fatal  were  acute  cases,  to  wTit,  two  for  acute  suppurative  arthritis 
of  the  knee-joint,  in  adults;  one  for  elephantiasis  and  sloughing  ulcer;  and 
one  for  popliteal  aneurism  which  had  become  diffuse.  Prof.  Spence's  statistics 
of  amputation  for  disease,  which  embrace  between  300  and  400  cases,14  showT 
that  while  the  mortality  of  amputation  for  chronic  disease  was  less  than  14 
per  cent.,  that  of  amputation  for  malignant  disease  was  over  46  per  cent.,  and 

1  Archives  Generales  de  Medeeine,  Mai,  1842,  pp.  59,  61. 

2  Bulletin  de  l'Academie  Imperiale  de  Medeeine,  tome  xxvii.  p.  591.  M.  Trelat's  Tables  contain 
1144  cases,  but  in  106  the  nature  of  the  lesion  is  not  recorded. 

3  Guy's  Hospital  Reports,  3d  s.  vol.  xxi.  p.  260. 

4  Medico-Chirurgieal  Transactions,  vol.  xlvii.  p.  80. 

6  St.  Bartholomew's  Hospital  Reports,  vol.  xiv.  Statistical  Tables,  p.  114. 
6  St.  George's  Hospital  Reports,  vol.  i.  p.  291,  and  vol.  viii.  p.  269. 

i  Lectures  on  Surgery,  vol.  ii.  ;  Medical  Times  and  Gazette,  October  28,  1876  ;  and  Edinburgh 
Medical  Journal,  November  and  December,  1879. 

8  Boston  Medical  and  Surgical  Journal,  vol.  lxxxvi.,  Supplement,  1871.  Dr.  Chadwick's  Tables 
contain  699  cases,  but  the  result  in  7  was  undetermined. 

9  Medical  and  Surgical  Reports  of  the  Boston  City  Hospital,  Second  series,  1877,  p.  291.  Dr. 
Gorman's  Tables  contain  299  eases,  hut  the  result  in  3  was  undetermined. 

10  American  Journal  of  the  Medical  Sciences,  April,  1881.  Dr.  Varick's  Tables  embrace  95 
cases,  lint  the  nature  of  the  lesion  in  5  cases  is  not  recorded. 

11  Pennsylvania  Hospital  Reports,  vol.  i.  p.  149;  American  Journal  of  the  Medical  Sciences, 
October,  L870,  ami  April,  1875  ;  and  Surgery  of  the  Pennsylvania  Hospital,  p.  31. 

'2  Vide  supra,  Table,  pp.  612-616. 

13  Guy's  Hospital  Reports,  3d  s.  vol.  xxi.  p.  260. 

14  Lectures  on  Surgery,  vol.  ii.  ;  Medical  Tunes  and  Gazette,  March  13,  1875,  and  Oct.  28,  1876; 
Edinburgh  Medical  Journal,  November  and  December,  lb79. 


MORTALITY  AND  CAUSES  OF  DEATH  AFTER  AMPUTATIONS.        G27 

that  of  amputation  for  acute  disease  (principally  acute  necrosis  of  the  femur) 
over  83  per  cent. 

Period  of  Amputation. — Amputations  for  injury  have  been  usually  divided 
by  surgical  writers  into  primary  or  immediate,  and  secondary  or  consecutive 
operations ;  but  a  better  classification  is  that  of  modern  army  surgeons,  who 
make  a  third  class — the  mediate,  intermediate,  or  intermediary — which,  in  point 
of  time,  find  a  place  between  the  other  two.  Primary  amputations  are  those 
done  before  the  development  of  traumatic  fever,  a  period  of  twenty-four, 
forty-eight,  or,  in  some  cases  in  which  shock  has  been  much  prolonged,  even 
as  much  as  seventy -two  hours;  intermediate  amputations  are  those  done  during 
the  existence  of  acute  inflammatory  symptoms,  a  period  variously  estimated 
at  from  two  to  four  weeks;  and  secondary  amputations  are  those  done  after 
the  subsidence  of  fever  and  the  occurrence  of  healthy  suppuration.1  It  has 
long  been  acknowledged  by  military  surgeons  that,  except  as  regards  opera- 
tions at  the  hip  or  upper  part  of  the  thigh,  primary  give  better  results  than 
secondary  amputations  f  but  the  contrary  has  been  very  commonly  asserted 
in  relation  to  civil  practice.  Bat  even  if  it  were  true  (which  it  is  not)  that 
the  death-rate  was  less  after  secondary  amputations,  this  would  by  no  means 
invalidate  the  propriety  of  prompt  operation  in  cases  which  require  such 
interference;  for  they  are,  in  the  first  place,  of  course  the  most  favorable 
cases,  in  which  conservative  treatment  is  attempted,  and  a  considerable  num- 
ber of  them  are,  moreover,  eliminated  by  death  during  the  intermediate 
period ;  so  that  the  cases  of  patients  who  survive  long  enough  to  submit  to 
secondary  amputation,  have  been,  as  it  were,  doubly  selected.  Intermediate 
operations  are  universally  acknowledged  to  give  worse  results  than  either 
primary  or  secondary,  and  experience  has  but  served  to  confirm  the  opinion 
advanced  long  ago  by  Benjamin  Bell,  that  "  unless  the  operation  .  .  .  can 
be  performed  soon  after  the  accident,  it  cannot  again  be  admissible  for  a  con- 
siderable time;  for  whenever  a  limb  has  become  swelled  and  inflamed,  it 
can  never,  but  with  the  utmost  danger,  be  taken  off  till  those  symptoms 
subside."3 

In  order  to  show  the  advantages  of  primary  amputation  in  civil  as  well  as 
in  military  practice,  I  have  prepared  the  following  Table  which  contrasts  the 
results  of  operations  for  injury  done  before  the  onset  of  inflammatory  fever 
with  those  done  at  a  later  period. 

1  M.  Verneuil  applies  to  these  three  classes  of  operation  the  names  of  antepyretic,  intrapyrdic, 
and  metapyretic,  respectively. 

2  The  reader  who  is  interested  in  reviewing  the  acrid  disputes  upon  this  question  in  times  gone 
by,  will  find  a  good  account  of  them  in  Malgaigne's  well-known  paper  in  the  Archives  Ge'ne'rales 
de  Medecine  for  April,  1842.  See  also  Memoires  de  l'Academie  Royale  de  Chirurgie,  tome  ii.  pp. 
199,  322,  and  tome  iv.  p.  133.     Paris,  1819. 

3  Op.  cit.,  vol.  vii.  p.  230. 


628 


AMPUTATIONS. 


Table  showing  the  Comparative  Results  of  Early  and  Late  Amputations 
for  Injury  in  Civil  Practice. 


Primary 

Secondary  and  Inter- 

mediate. 

Keporter. 

Cases. 

Deaths. 

Mort. 
per  ct. 

Cases. 

Deaths. 

Mort. 
per  ct. 

Reference. 

Malgaigne 

49 

34 

69.4 

20 

13 

65.0 

Archives  Generates  de  Medecine,  Mai, 
1842. 

James 

64 

15 

23.4 

28 

10 

35.7 

Trans.  Prov.  Med.  and  Surg.  Assoc, 
vol.  xvii. 

South 

18 

7 

38.9 

5 

2 

40.0 

Notes  to  Chelius's  Surgery,  vol.  iii. 
Philadelphia,  1847. 

Laurie 

74 

39 

52.7 

43 

26 

60.5 

James,  loc.  cit. 

Steele 

169 

62 

36.7 

53 

37 

69.8 

Ibid. 

McGhie 

180 

60 

33.3 

87 

61 

70.1 

Macleod,  Surgery  of  Crimean  War,  p. 
367.    Philadelphia,  1862. 

Hussey 

50 

9 

18.0 

6 

1 

16.6 

Ibid. 

Erichsen 

48 

18 

37.5 

43 

19 

44.2 

Science  and  Art  of  Surgery,  vol.  i.  p. 
121.     Philadelphia,  1878. 

Parker 

40 

8 

20.0 

9 

6 

6G.Q 

Cooper's  Surgical  Dictionary,  vol.  i. 
p.  121. 

Femvick 

71 

23 

32.4 

10 

3 

30.0 

Ibid. 

Callender 

93 

15 

16.1 

37 

13 

35.1 

Medico-Chirurgical   Transactions,  vol. 

xlvii. 
Guy's  Hospital  Reports,  3d  series,  vol. 

Golding-Bird 

240 

104 

43.3 

94 

53 

56.4 

Spence 

144 

60 

41.6 

42 

17 

40.4 

Lectures  on  Surgery,  vol.  ii.  ;  Med. 
Times  and  Gaz.,  Oct.  28,  1876  ;  and 
Edin.  Med.  Journal,  Nov.  and  Dec. 

1879. 

Buel 

37 

12 

32.4 

24 

7 

29.1 

Am.  Journ.  of  Med.  Sciences,  1848. 

Lente 

29 

14 

48.3 

13 

7 

53.8 

Trans.  Amer.  Med.  Association,  vol.  iv. 

Chadwick 

241 

84 

34.9 

87 

32 

36.8 

Boston  Med.  and  Surg.  Journal,  1871. 

Gorman 

164 

68 

41.5 

50 

21 

42.0 

Boston  City  Hospital  Reports,  1877. 

Varick 

75 

31 

41.3 

5 

•  4 

80.0 

Amer.  Journ.  of  Med.  Sciences,  1881. 

Morton 

656 

164 

25.0 

118 

45 

38.1 

Surgery  in  the  Pennsylvania  Hospital. 
Philadelphia,  1880. 

Author 

55 

16 

29.4- 

17 

8 

47.4- 

Supra,  p.  612. 

Totals 

2497 

843 

33.7 

791 

385 

48.6 

From  this  Table  it  will  be  seen  that  the  statistics  of  all  but  five  of  the 
twenty  authors  whom  I  have  quoted,  show  that  primary  amputations  are  the 
most  successful,  and  that,  taking  the  aggregate  cases  of  the  whole  twenty,  the 
death-rate  of  the  early  operations  is  but  one  in  three,  while  that  of  the  late 
operations  is  nearly  one  in  two.  rutting  the  figures  in  another  way,  the 
mortality  of  early  is  less  than  that  of  late  operations,  nearly  in  the  ratio  of 
two  to  three,  and,  comparing  this  with  the  preceding  Table,  it  appears  that 
primary  are  as  much  more  successful  than  other  traumatic  amputations  in  civil 
practice,  as  amputations  for  disease  are  than  amputations  for  injury  taken  all  to- 
gether. The  difference  is  even  more  marked  than  in  military  practice,  as  may 
be  seen  from  the  following  Tabic: — 


MORTALITY  AND  CAUSES  OF  DEATH  AFTER  AMPUTATIONS. 


629 


Table  showing  the  Comparative  Results  of  Early  and  Late  Amputations 

in  Military  Surgery. 


Primary. 

Secondary  and  Inter- 
mediate. 

Reporter. 

Cases. 

Deaths. 

Mort. 
per  ct. 

Cases. 

Deaths. 

Mort. 
per  ct. 

Reference. 

Macleod 

Legouest 

Otis1 

1047 
4038 
4806 

.374 

2530 

821 

35.7 
62.6 
17.4- 

594 

999 

2182 

314 

680 
644 

52.8 

68.+ 

29.5 

Notes  on  the  Surgery  of  the  War  in  the 

Crimea,  p.  367.    Philadelphia,  1862. 
Traite  de  Chirurgie  d'Arniee,  pp.  705, 

706.    Paris,  1863. 
Medical  and  Surgical   History  of  the 

War  of  the  Rebellion,  Part  Second, 

Surgical  volume. 

Totals 

9891 

3725 

37.6 

3775 

1638 

43.3 

I  am  not  aware  of  the  existence  of  any  statistics  to  show  the  comparative 
mortality  of  intermediate  and  secondary  amputations  in  civil  practice,  and 
indeed,  in  civil  hospitals,  it  very  seldom  happens  that  limbs  are  removed  dur- 
ing the  intrapyretic  period.  Only  twice,  in  my  own  experience,  have  I  felt 
it  my  duty  to  resort  to  intermediate  amputation,  and  in  both  of  these  cases 
the  patients  succumbed,  though  perhaps  not  much  sooner  than  they  would 
have  done  from  the  effects  of  their  injuries,  complicated  as  they  were  by 
spreading  gangrene,  had  no  operation  been  performed.  In  military  practice 
the  greater  gravity  of  intermediate  amputations  has  been  clearly  established; 
thus  of  the  2182  late  operations  with  644  deaths,  recorded  by  Dr.  Otis,  and 
included  in  the  preceding  Table,  1516  were  intermediate,  with  481  deaths,  or 
31.7  per  cent.,  and  666  secondary,  with  163  deaths,  or  only  24.4  per  cent. 

Part  of  the  Body  Involved. — There  remains  to  be  considered  the  influence 
On  the  result  of  amputation  exercised  by  the  locality  of  the  operation,  or,  in 
other  words,  the  particular  part  of  the  body  in  which  the  amputation  is  per- 
formed. In  general  terms,  it  may  be  said  that  amputations  in  the  lower  are 
more  serious  than  those  in  the  upper  extremity,  and  that  the  nearer  to  the 
trunk  is  the  seat  of  operation,  the  greater  is  the  risk  to  life.  To  illustrate 
these  points,  I  have  prepared  the  following  Table,  in  which  is  compared  the 
mortality  of  the  four  principal  amputations,  those  of  the  thigh,  leg,  arm,  and 
forearm. 

1  Amputations  of  upper  extremity  only. 


630 


AMPUTATIONS. 


Table  showing  the  Mortality  of  Amputation  in  Different  Parts  of  the 

Body. 


Forearm 

. 

Arm. 

Leg. 

Thigh. 

Authority. 

Cases. 

Deaths. 

Mort. 
per  ct. 

Cases. 

Deaths. 

Mort. 
per  ct. 

Cases. 

Deaths. 

Mort. 
per  ct. 

Cases. 

Deaths. 

Mort. 
per  ct. 

Malgaigne1 

28 

8 

28.5 

91 

41 

45.4- 

192 

106 

55.2 

201 

126 

62.6 

Trelat2 

44 

16 

36.3 

141 

60 

42.5 

418 

184 

44.4- 

360 

190 

52.7 

Golding-Bird3 

84 

14 

16.6 

91 

24 

26.3 

271 

97 

35.7 

370 

132 

35.6 

Callender4 

64 

3 

4.6 

78 

10 

12.8 

193 

61 

31.6 

233 

80 

34.3 

Holmes4 

56 

7 

12.5 

51 

14 

27.4 

137 

44 

32.1 

220 

81 

36.8 

Spence6 

47 

11 

23.4 

42 

15 

35.7 

66 

18 

27.2 

186 

64 

34.4 

Chadwick7 

68 

13 

19.1 

76 

14 

18.6 

267 

66 

24.7 

236 

68 

28.8 

Gorman8 

37 

5 

13.5 

52 

14 

26.9 

71 

23 

32.3 

89 

48 

53.9 

Varick9 

14 

2 

14.2 

15 

7 

46.6 

15 

7 

46.6 

38 

19 

50.0 

Morton10 

165 

18 

10.9 

157 

32 

20.3 

314 

106 

33.7 

137 

46 

33.5 

Legouest11 

447 

202 

45.1 

1142 

559 

48.9 

930 

478 

51.3 

1919 

1686 

87.8 

Otis'2 

1748 

245 

14.4-  5327 

1273 

23.8 

2348 

611 

26.4- 

1597 

1029 

64.4 

Author13 

18 

5 

27.7       21 

6 

28.5 

25 

3 

12.0 

20 

8 

40.0 

Aggregates 

2820 

549 

19.4    7284 

2069 

28.4 

5247 

1804 

34.3 

5606 

3577 

63.8 

Macleod. 

Legouest 

86.8 

87.2 

55.3 

58.5 

50.0 

55.0 

From  the  above  Table  it  appears  that  while  the  mortality  of  amputations 
of  the  forearm  has  been  less  than  20  per  cent.,  or  one  in  five,  and  that  of 
amputations  of  the  upper  arm  but  little  over  28  per  cent.,  or  one  in  four,  the 
death-rate  of  amputations  of  the  leg  has  been  more  than  34  per  cent.,  or  over 
one  in  three,  and  that  of  amputations  of  the  thigh  almost  64  per  cent.,  or  nearly 
two  in  three. 

The  fact  that  the  gravity  of  amputation  increases  as  the  trunk  is  ap- 
proached, is  also  seen  by  comparing  the  results  of  amputations  in  different 
parts  of  the  thigh;  the  following  are  the  death-rates  given  by  Macleod  and 
Legouest  for  operations  in  the  upper,  middle,  and  lower  thirds  respectively : — 

Amputations  in  the  upper  third  of  the  thigh 

middle         "         "  ... 

"  "         lower  "         "  ... 

Apart  from  the  proximity  to  the  trunk,  the  particular  part  of  the  bone 
which  is  divided  in  an  amputation,  exercises  an  influence  on  the  result  of  the 
operation,  suppurative  osteomyelitis  and  consequent  pyaemia  being  more  apt 
to  follow  when  the  medullary  cavity  of  a  long  bone  is  laid  open,  than  when 
only  the  cancellous  structure  is  involved.  Thus  of  295  cases  of  pyaemia 
following  amputation,  referred  to  by  Otis,14 155,  or  more  than  52  per  cent., 
were  after  amputation  through  the  shaft  of  the  femur. 

1  Archives  Generales  de  Medecine,  Avril,  1842,  pp.  402-411. 

2  Bulletin  de  l'Academie  Imperiale  de  Medecine,  t.  xxvii.  p.  591,  and  Legouest,  Traite  de 
Chirurgie  d'Armee,  pp.  722—736.     Paris,  1863. 

3  Guy's  Hospital  Reports,  3d  s.,  vol.  xxi.  p.  260. 

*  St.  Bartholomew's  Hospital  Reports,  vol.  v.  p.  247. 

6  St.  George's  Hospital  Reports,  vol.  i.  pp.  293-299,  and  vol,  viii.  pp.  276-283. 

6  Lectures  on  Surgery,  vol.  ii.  ;  Med.  Times  and  Gazette,  March  13,  1875,  and  Oct.  28,  1876; 
iburgh  Medical  Journal,  November  and  December,  L879. 

7  Boston  Medical  and  Surgical  Journal,  1871.     Supplement. 

8  Medical  and  Surgical  Reports  of  the  Boston  City  Hospital,  2d  series,  1877,  p.  316. 
,J  American  Journal  of  the  Medical  Sciences,  April,   1SSI,  p.  438. 

i"  Surgery  in  the  Pennsylvania  Hospital,  etc.,  ]>.  'VI.     Philadelphia,  1880. 
"  Traite  de  Chirurgie  d'Armee,  pp.  722-736.     Paris.  1863. 

12  Circular  No.  6,  S.  G.  0.  Washington,  1865  ;   and  Medical  and  Surgical  History  of  the  War  of 
the  Rebellion.     Part  Second,  Surgical  volume. 

13  Supra,  p.  612. 

14  Circular  No.  6,  S.  G.  O.  Washington,  1865,  p.  43. 


AMPUTATIONS   OF    THE   FINGERS.  G31 


SPECIAL  AMPUTATIONS  OF  THE  UPPER  EXTREMITY. 

Amputations  of  the  Fingers. 

The  surgeon  is  frequently  called  upon  to  amputate  a  part  or  the  whole  of  a 
finger,  or  even  several  ringers,  in  cases  of  injury  by  gunshot  wound  or  ma- 
chinery, neglected  felon,  destruction  of  the  interphalangeal  joints  by  syphilitic 
disease,  etc.  As  no  artificial  substitute  can  possibly  replace  even  for  a  moder- 
ate degree  of  usefulness,  the  natural  finger,  it  should  be  the  surgeon's  aim  to 
save  every  portion  that  can  possibly  be  preserved;  hence,  if  part  of  a  phalanx 
can  be  left,  this  should  be  done,  rather  than  amputate  at  the  joint  above. 
The  only  exception  to  this  rule  is  in  the  case  of  the  proximal  phalanges  of 
the  middle  and  ring  fingers;  as  there  is  no  special  flexor  tendon  for  these 
parts,  they  are  apt,  if  preserved,  to  project  stiffly,  and  to  rather  hinder  than 
assist  the  usefulness  of  the  rest;  hence  when,  in  these  fingers,  it  is  necessar v 
to  remove  all  except  the  proximal  phalanges,  it  is  proper  to  take  these  away 
also,  and  amputate  at  the  phalangeo-metacarpal  joint.  In  the  case  of  the 
forefinger,  however,  even  part  of  a  phalanx  is  of  value,  as  affording  a  point 
of  opposition  to  the  thumb,  while  in  the  little  finger,  the  proximal  phalanx 
may  be  kept  in  order  to  give  greater  symmetry  to  the  hand  than  it  would 
otherwise  possess. 

Amputation  through  a  Phalanx  may  be  most  conveniently  done  by  the 
flap  method;  either  by  the  old  plan  of  Heliodorus  (generalized  by  Ravaton), 
of  making  a  circular  incision  down  to  the  bone,  and  then  forming"  two  scpiare 
flaps  by  adding  longitudinal  incisions  on  either  side ;  or  by  shaping  antero- 
posterior, semicircular  flaps  from  without  inwards.  The  bone  may  be  divided 
either  with  a  small  saw  or  with  cutting  pliers,  and  the  wound  accurately 
closed  with  three  or  four  points  of  the  metallic  suture.  Two  vessels  usually 
bleed — the  digital  arteries  on  either  side — and  these  can  commonly  be  con- 
trolled by  passing  the  stitches  through  their  mouths,  without  the  use  of 
ligatures.  The  whole  hand  and  forearm  should  be  placed  upon  a  well-padded 
splint,  and  thus  kept  at  rest  for  about  a  week  after  the  operation. 

Amputation  through   either  of  the  Interphalangeal  Joints   may  be 
readily  effected  by  the  single  (palmar)  flap,  or  by  the  double  flap  method. 
The  circular  operation  has  also  been  em- 
ployed in  disarticulations  of  the  phalanges,  Fig.  166. 
but  seems  to  me  to  be  less  advantageous 
than  the  flap  method  in  this  locality.     The 
most  important  point  to  be  borne  in  mind, 
in   these   operations,  is   that  the  joint  is 
always  found  below  the  prominence  of  the 
knuckle,  which  is  caused  by  the  projection 
of  the  upper  bone,  as  shown  in  the  accom- 
panying illustration  (Fig.  166),  suggested  by 
a  cut  in  M.  Fort's  excellent  work  on  Opera- 
tive Surgery ;  in  the  case  of  the  last  or  distal       „,  ,  .      ,    .         .     .     ^    ,   .      . 

.      -.  s    -i        t  n  ••         •  7-  -i  Skeleton  of  a  finger,  showing  the  relation  of 

phalanx,  the  line  ot  the  joint  is  one  line  {■£%  the  knuckles  to  the  joints. 


632 


AMPUTATIONS. 


Amputation  of  finger  by  palmar  flap  method. 


inch)  below  the  most  projecting  part  of  the  knuckles;  in  that  of  the  middle 
phalanx,  two  lines  (\  inch)  below;  and  in  that  of  the  first  or  proximal  phalanx, 
four  lines  (J  inch)  below  the  corresponding  prominence.  It  will  be  found 
convenient,  in  disarticulating  the  phalanx,  to  employ  a  slender  and  rather 
short  knife,  with  a  heavy  back.     (Fig.  121.) 

(1)  Single  Flap  Operation. — The  flap  is  usually  and  preferably  taken  from 
the  palmar  surface  (Fig.  167),  which  affords  a  firm  covering  for  the  stump, 
and  one  which  at  the  same  time  possesses  tactile  sensibility.  Le  Dran,  how- 
ever, preferred  to  take  a  flap  from 
the  side  of  the  linger,1  while  La 
Roche  and  Walther  took  one  from 
the  back  ;2  the  only  advantage  of 
this  plan  was  that  the  resulting 
cicatrix  was  less  apparent,  whence 
A.  Gruerin  tells  us  that  it  was  called 
the  "rich  man's  operation."3  The 
palmar  flap  may  be  cut  either  by 
transfixion  or  from  without  in- 
wards, and  its  formation  may  con- 
stitute  either    the   first   or  second 

stage  of  the  operation.  If  the  flap  is  to  be  made  first,  the  patient's  hand 
should  be  held  in  a  supine  position,  and  the  knife  entered,  in  the  case  of  the 
last  phalanx  a  little  below,  and  in  that  of  the  middle  phalanx  on  a  level 
with,  the  palmar  crease  corresponding  to  the  articulation.  The  flap  should 
be  a  little  longer  than  the  diameter  of  the  finger,  and  its  width  should  be  as 
nearly  as  possible  half  the  circumference;  its  ends  should  be  rounded,  but  not 
too  much  bevelled,  for  fear  of  sloughing.  If  transfixion  is  employed  (Lis- 
franc's  method),  the  knife  must  be  kept  close  to  the  bone,  or  the  flap  will  be 
too  narrow.  The  flap  having  been  formed,  the  knife  is  turned  with  its  edge 
towards  the  joint,  at  the  upper  part  of  the  wound,  and,  the  palmar  and  lateral 
ligaments  having  been  divided,  disarticulation  is  effected,  and  the  structures 
on  the  back  of  the  finger  severed  at  a  single  stroke.  A  better  plan  is,  I 
think,  to  attack  the  joint  from  its  dorsal  surface,  the  hand  being  held  prone, 
and  the  finger  flexed  till  the  joint  has  been  opened  and  the  lateral  ligaments 
divided ;  then  the  knife,  placed  at  the  bottom  of  the  wound,  is  turned  flat- 
wise, and,  the  finger  being  extended,  a  flap  of  sufficient  length  and  breadth 
is  cut  by  a  sawing  motion.  A.  Guerin  prefers  to  make  the  flap  first,  by  trans- 
fixion, as  in  Lisfranc's  method,  and  then,  having  pronated  the  patient's  hand, 
to  open  the  joint  and  effect  disarticulation  from  the  dorsal  surface. 

(2)  Double  Flap  Operation. — Where  the  surgeon  has  the  opportunity  of 
choosing  his  mode  of  amputating  through  one  of  the  interphalangeal  joints, 
the  single  palmar  flap  method  gives,  I  think,  the  best  result;  but  it  may 
happen,  in  cases  of  lacerated  wound,  etc.,  that  the  palmar  tissues  are  deficient, 
and  that  the  operator  must  either  utilize  the  structures  on  the  back  of  the 
finger,  or  remove  more  of  the  bone  than  is  desirable.  Under  these  circum- 
stances both  a  dorsal  and  a  palmar  flap  may  be  formed,  by  cutting  from  with- 
out, inwards,  disarticulation  being  then  effected,  and  the  operation  completed, 
in  the  manner  already  described.  This,  which  is  the  plan  recommended  by 
Richerand  and  Gouraud,  seems  to  me  to  be  in  every  way  preferable  to  the 
lateral-flap  operation  of  Maingault. 

Amputation  of  an  Entire  Finger. — Disarticulation  at  the  metacarpo- 
phalangeal joint  of  any  of  the  fingers  may  be  conveniently  accomplished  by 


1  Dnbreuil,  Manuel  d'Oporatious  Chirurgicales,  p.  86.     Paris,  18G7. 
8  Ibid.  3  Op.  cit.,  p.  108. 


AMPUTATIONS   OF   THE   FINGERS. 


633 


the  oval  method  of  Scoutetten,  or,  which  is  better,  its  modification,  the  ope- 
ration u  en  raquette"  of  Malgaigne;  by  the  double  (lateral)  flap  method;  or,  in 
the  case  of  the  thumb,  by  taking  a  single  flap  from  either  the  dorsal  or  the 
palmar  surface.  The  circular  and  elliptical  operations  have  also  been  em- 
ployed in  this  situation,  but  are  less  desirable  than  those  above  mentioned. 

(1)  Oval  Method. — The  simple  oval  method,  or  that  of  Scoutetten  (see  Fio-. 
149,  a,  page  584),  has  the  disadvantage  of  often  not  affording  a  sufficient 
covering  for  the  head  of  the  metacarpal  bone,  and  I  shall,  therefore,  describe 
Malgaigne's  modification  only,  which  is  not  open  to  this  objection.  In  per- 
forming this  operation  (Fig.  149,  b),  the  hand  of  the  patient  should  be  pro- 
nated,  and  the  surgeon  begins  by  making  a  longitudinal  incision  of  half  or 
three-quarters  of  an  inch  over  the  head  of  the  metacarpal  bone ;  from  the 
lower  third  of  this  wound,  the  knife  is  carried  obliquely  downwards  on  the 
right  side  to  the  interdigital  web,  then  transversely  across  the  base  of  the 
finger,  and  finally  obliquely  upwards  to  again  join  the  longitudinal  incision. 
All  the  tissues  down  to  the  bone  should  be  divided,  when,  the  joint  having 
been  exposed  by  a  little  dissection,  the  extensor  and  flexor  tendons,  and 
lateral  ligaments,  are  severed,  and,  disarticulation  being  thus  completed,  the 
sides  of  the  wound  are  finally  brought  together  in  an  antero-posterior  direc- 
tion. In  the  case  of  the  forefinger,  however,  the  point  of  the  oval  should  be 
on  the  radial,  and  in  the  case  of  the  little  finger,  on  the  ulnar  side  of  the 
joint ;  and  in  these  cases  the  wound  should  be  closed  transversely. 

(2)  Double  Flap  Method. — In  this  operation  (Fig.  168),  lateral  flaps  are  cut 
from  without  inwards,  from  either  side  of  the  finger  which  is  to  be  removed. 
This  plan,  which  is  known  as  Petit's,  is  I  think  better 
than  either  that  of  Rossi,  who  made  both  flaps  by 
transfixion,  or  that  of  Lisfranc,  who  cut  one  flap  from 
without  inwards,  before  disarticulating,  and  the  other 
subsequently  from  within  outwards.  Sharp's  and  Ga- 
rengeot's  methods,  in  which  antero-posterior  flaps  were 
employed,  are  also  less  desirable  than  Petit's.  The  ad- 
vantage of  this  operation  over  the  oval  method,  is  that 
is  does  not  leave  a  pocket  of  palmar  tissue,  in  which  pus 
may  accumulate;  but,  on  the  other  hand,  the  oval 
method  leaves  the  palm  entirely  free  from  the  cicatrix, 
and  thus  gives  at  last  a  better  result,  though  the  wound 
may  not  heal  as  quickly  as  after  the  flap  operation. 

(3)  Single  Flap  Method. — This  operation,  which  is 
known  as  Chassaignac's,  seems  to  be  less  advantageous 
than  either  the  oval  or  double  flap  method,  except  in 
the  case  of  the  thumb.  The  flap  may  be  taken  from 
either  the  dorsal  or  palmar  surface,  the  latter  plan 
being,  I  think,  preferable.  The  joint  is  opened  at  the 
back,  and,  after  disarticulating,  the  flap  is  cut  from 
within  outwards  as  in  the  case  of  the  interphalangeal 
amputations  which  have  already  been  described. 

Some  surgeons  advise  that  the  head  of  the  metacarpal  bone  should  be 
removed,  in  these  amputations,  in  order  to  render  the  loss  of  the  finger  less 
apparent  by  permitting  the  others  to  come  more  closely  together ;  but  what 
is  gained  in  symmetry,  is  no  compensation  for  the  loss  of  strength  in  the 
hand,  thus  entailed;  there  is,  moreover,  a  positive  risk  in  thus  opening  the 
deep  structures  of  the  palm,  suppuration  in  that  part  being  extremely  painful, 
and  apt  to  extend  upwards  along  the  planes  of  connective  tissue  in  the  forearm, 
thus  causing  prolonged  disability  and  even  endangering  life. 


Amputation  of  entire  finger  by 
double  flap  method. 


634 


AMPUTATIONS. 


Fig.  169. 


Amputation  of  two  fingers  by 
oval  method. 


Amputation  of  two  Adjoining  Fingers  simulta- 
neously, at  their  metacarpal  articulations,  may  be 
effected  by  the  circular,  oval  (en  raquette,  Fig.  169),  or 
elliptical  methods,  or  by  taking  a  flap  from  the  palm 
(Lisfranc),  or  from  the  side  of  one  finger  (Chassaignac). 
A  better,  if  less  brilliant,  plan  is,  I  think,  to  amputate 
each  finger  separately  by  whatever  method  seems  best 
adapted  to  the  particular  requirements  of  the  case. 

Amputation  of  the  Four  Fingers  simultaneously, 
may  likewise  be  done  by  the  circular,  elliptical,  or 
palmar-flap  methods,  the  elliptical  operation  being 
brobably  the  best  of  the  three.  Here,  too,  I  think 
that  the  surgeon  will  usually  do  better  to  forego  bril- 
liancy, and  remove  each  finger  separately  in  whatever 
way  may  seem  best. 


Amputations  of  the  Hand. 


Partial  amputations  of  the  hand  are  not  unfre- 
quently  required  in  cases  of  laceration  by  gunshot  in- 
jury or  by  machinery,  and  there  are  no  cases  which 

more  than  these  test  the  ingenuity  and  skill  of  the  surgeon  in  preserving  for 

his  patient  a  useful  member.     The  thumb  is  of  more  value  than  any  other 

part  of  the  hand,  and  an  effort 
Fig.  170.  should  be  made  to  save  every 

portion  that  is  not  hopelessly 
injured.  I  have  removed  all  of 
the  hand,  except  the  thumb, 
through  the  metacarpus ;  have 
saved  the  thumb  and  forefinger, 
removing  the  rest  of  the  hand 
quite  up  to  the  wrist ;  and  have 
similarly  preserved  the  thumb 
and  little  finger  (Fig.  170),  or 
even  a  single  finger,  with  its 
metacarpal  bone,  the  wThole  car- 
pus being  removed,  and  the  part 

of  the  hand  that  was  left  being  allowed  to  be  gradually  drawn  up  in  contact 

with  the  bones  of  the  forearm. 

Amputation  of  the  Thumb  through  its  Metacarpal  Bone  may  be  best 
effected  by  the  oval  (en  raquette)  method,  the  point  of  the  oval  being  placed 
on  the  outer  side,  and  the  bone  divided  at  the  required  point  with  strong 
cutting  pliers.     This  operation  is  very  seldom  practised. 

Amputation  of  the  Thumb  with  its  Metacarpal  Bone  may  be  conveniently 
effected  by  either  the  oval  (en  raquette),  or  the  flap  method,  and,  if  the  latter 
l)c  employed,  the  flap  may  be  taken  either  from  the  outer  (radial)  side  of  the 
hand,  or  from  the  palmar  surface. 

(1)  Oval  Method.—  If  this  operation  be  practised,  the  point  of  the  oval  should 
be  placid  upon  the  dorsal  surface,  and  should  be  prolonged  upwards  as  far  as 
the  carpo-metacarpal  articulation  ;  the  sides  of  the  wound  are  brought  to- 


,0? 

J   f  '        ,nf,  lii'"^** 

Result  of  partial  amputation  of  hand,  the  thumb  and  little 
finger  being  preserved. 


AMPUTATIONS   OF   THE   HAND. 


635 


gether  in  a  longitudinal  direction,  and  the  resulting  cicatrix  is  small  and  well 
protected. 

(2)  External  Flap  Method. — The  formation  of  the  flap  may  be  either  the 
first  or  the  last  step  of  the  operation.  If  the  former  plan  is  to  be  adopted, 
the  patient's  thumb  is  forcibly  abducted,  the  hand  being  supinated  for  the 
right  and  pronated  for  the  left  side.  The  knife  is  applied  to  the  interdigital 
web,  and  made  to  cut  its  way  upward  with  a  sawing  motion  until  the  joint 
is  reached ;  then  the  edge  of  the  knife  is  turned  outwards,  disarticulation 
effected,  and,  the  tissues  being  pushed  to  the  radial  side,  the  flap  is  made  by 
cutting  downwards  for  a  sufficient  distance,  grazing  the  bone,  and  finally 
outwards.  If  preferred,  the  flap  may  be  formed  first,  either  by  transfixion 
or  by  cutting  from  without  inwards,  disarticulation  effected  from  the  outer 
side  of  the  joint,  and  the  tissues  of  the  interosseous  space  divided  as  the  last 
step  of  the  operation. 

(3)  Palmar  Flap  Method. — This  variety  of  amputation,  which  is  known  as 
Chassaignac's,  gives  a  result  closely  approximating  to  that  of  the  oval  method. 
In  the  case  of  the  right  thumb,  the  flap  is  made  by  transfixion,  a  strong  but 
slender  knife  being  inserted  just  in  front  of  the  carpo-metacarpal  joint,  thrust 
downwards  till  its  point  emerges  at  the  interdigital  web,  and  then  made  to 
cut  its  way  out  opposite  the  metacarpophalangeal  joint,  thus  forming  an  oval 
flap  from  the  palm;  disarticulation  is  next  effected  (Fig.  171),  and  "the  ends 
of  the  first  wound  united  by  cutting  through  the  dorsaf  tissues  from  without 
inwards.     In  the  case  of  the  left  thumb  (Fig.  172)  the  dorsal  incision  is  made 


Fig.  171. 


Fig.  172. 


Amputation  of  right  thumb  by  palmar  flap  method. 
The  flap  has  been  formed,  and  the  knife  is  effecting  dis- 
articulation. 


Amputation  of  left  thumb  by  palmar  flap  method. 


first,  disarticulation  effected  from  behind,  and  the  knife,  being  thrust  in  front 
of  the  bone,  made  to  cut  the  palmar  flap  of  the  requisite  size  and  Bhape,  as 
it  is  brought  out  with  a  sawing  motion. 

Of  these  various  methods,  I  "decidedly  recommend  the  first  (oval  method), 
as,  though  less  brilliant,  giving  a  better  result  than  either  of  the  others. 

_  Amputation  through  One  or  More  Metacarpal  Bones  may  often  be  prac- 
tised with  advantage.      The  oval  method  (en  raquette)  may  be  conveniently 


636 


AMPUTATIONS. 


Fig.  173. 


adopted  in  these  operations,  the  point  of  the  oval  being  placed  upon  the  dor- 
sal, or,  in  the  case  of  the  fifth  metacarpal ,  upon  the  inner  (ulnar)  surface.  In 
many  cases,  however,  the  laceration  of  the  soft  parts  will  he  such  that  no 
regular  procedure  can  be  followed,  but  the  surgeon  will  be  compelled  to  secure 
a  covering  for  the  bone  from  any  portion  of  tissue  which  is  uninjured. 

Amputation  of  the  Fifth  Metacarpal  Bone  may  be  effected  by  either  the 
oval  {en  raquette),  or  the  internal  flap  method,  the  former,  as  in  the  case  of  the 

thumb,  being  preferable,  inas- 
much as  the  resulting  cicatrix  is 
smaller  and  better  protected.  The 
point  of  the  oval  may  be  placed 
either  on  the  dorsal,  or  on  the 
inner  (ulnar)  surface  of  the  hand, 
and  prolonged  upwards  as  far  as 
the  carpo-metacarpal  joint.  If 
the  flap  method  (Fig.  173)  be 
employed,  the  flap,  which  is 
formed  from  the  tissues  on  the 
inner  (ulnar)  side  of  the  hand, 
may  be  made  either  before  or 
after  dividing  the  interosseous 
structures,  and  either  by  trans- 
fixion or  by  cutting  from  without 

Amputation  of  fifth  metacarpal  by  internal  flap  method.  lllWarClS. 

Amputation  of  the  Metacarpal  Bone  of  either  the  Fore,  Middle,  or 
Ring  Finger,  or  of  two  or  more  of  them  simultaneously,  may  be  best  done  by 
the  oval  {en  raquette)  method,  the  point  of  the  oval  being  placed  upon  the  back 
of  the  hand,  beginning  from  a  third  to  half  an  inch  above  the  line  of  the  articu- 
lation. In  order  to  gain  more  ready  access  to  the  joint,  Seclillot  advices  that 
a  short  transverse  incision  should  be  made  at  the  upper  end  of  the  oval,  so  as 
to  mark  out  two  triangles  of  tissue,  which  may  then  be  raised  as  lateral  flaps. 

Amputation  of  the  Ulnar  portion  of  the  Metacarpus,  involving  the  fourth 
and  fifth  metacarpals,  or  these  together  with  the  third,  may  also  be  conve- 
niently done  by  the  oval  method,  the  point  of  the  oval  in  this  case  being 
placed  on  the  ulnar  side.  Dorsal  and  palmar  flaps  are  employed  by  some  sur- 
geons in  the  performance  of  this  and  the  preceding  form  of  amputation,  but 
the  flap  method,  in  this  situation,  seems  to  me  more  complicated,  and  in  no 
respect  more  advantageous,  than  the  simpler  oval  operation  which  I  have 
described. 

Amputation  of  the  Entire  Metacarpus,  except  the  Thumb,  is,  however, 
besl  done  by  taking  a  palmar  flap,  cut  from  without  inwards.  An  excellent 
stump  is  thus  produced,  and,  the  thumb  remaining,  one  which  will  prove  of 
great  value  to  the  patient. 

Amputation  of  the  Entire  Metacarpus,  including  the  Thumb,  and  Am- 
putation between  the  two  rows  of  the  Carpus,  may  both  be  effected  by 
either  the  circular,  elliptical,  or  antero-posterior  flap  method.  Neither  of 
these  operations,  however,  presents  any  particular  advantage,  and  both  seem 
to  me  less  desirable  than  amputation  at  the  wrist,  suppuration  being  apt  to 
occur  in  the  inter-carpal  joints,  when  they  have  once  been  opened,  and  ne- 
crosis of  the  carpal  bones  often  following,  and  of  course  delaying  recovery. 


AMPUTATION  AT    THE   WRIST. 


637 


Excision  may  be  sometimes  substituted  for  amputation  of  a  metacarpal 
bone,  when  the  finger  itself  is  not  injured,  but  such  an  operation  is  not  usu- 
ally very  satisfactory.  Prof.  Joseph  Pancoast  has  successfully  adapted  a  fin- 
ger which  had  lost  its  metacarpal  bone,  to  another  metacarpal  bone  which 
had,  in  turn,  lost  its  finger.  After  all  amputations  of  the  hand,  as  after  those 
of  the  lingers,  the  part  should  be  kept  upon  a  splint  until  the  deep  parts  of 
the  wound  have  united. 

The  risk  of  amputation  below  the  wrist  is  very  slight.  I  have  kept  no 
record  of  my  own  finger  amputations,  but  do  not  recall  any  wrhich  have 
terminated  unfavorably.  Thirteen  cases  of  partial  amputation  of  the  hand, 
of  which  I  have  notes,  all  ended  in  recovery.  The  following  Table  exhibits 
the  mortality  of  these  operations  in  hospital  and  army  practice ;  the  death- 
rate  of  finger  amputations  is  seen  to  be  but  about  one  in  thirty,  and  that  of 
amputations  through  the  hand,  about  one  in  fifteen. 

Table  showing  the  Mortality  of  Amputations  of  the  Fingers  and 
Partial  Amputations  of  the  Hand. 


Fingers  or  Thumb. 

Fartial  of  Hand. 

Authority. 

Cases. 

Deaths. 

Mortality 
per  cent. 

•  Cases. 

Deaths. 

Mortality 
per  cent. 

Malgaigne1         .... 
Legouest2 ..... 

Otis3 

Morton4     ..... 
Author5     ..... 

165 

320 

5739 

15 

45 

129 

9.4- 

14.4- 

2.2 

9 

53 

950 

58 

13 

1 

21 

50 

0 

0 

11.1 

39.6 

5.4- 

0.0 

0.0 

Totals 

6224 

189 

3.3 

1083 

72 

6.6 

Amputation  at  the  "Wrist. 

The  whole  hand  may  be  removed  at  the  radio-carpal  articulation,  by  either 
the  circular,  the  elliptical,  or  some  variety  of  the  flap  method.  The  result- 
ing stump  is  usually  a  very  good  one,  and  possesses  the  advantage  of  allowing 
.the  retention  of  the  motions  of  pronation  and  supination,  but,  on  the  other 
hand,  is  said  to  be  less  well  fitted  than  a  shorter  stump  for  the  adaptation  of 
an  artificial  hand. 

Circular  Method. — The  back  of  the  hand  and  forearm  having  been 
shaved,  if  necessary,  and  the  tourniquet  adjusted  so  as  to  control  the  circula- 
tion through  the  brachial  artery,  an  assistant  grasps  the  hand  and  holds  it 
firmly,  wdiile  the  surgeon  with  his  own  left  hand  draws  the  skin  of  the  fore- 
arm upwards,  and  makes  his  first  incision  on  a  level  with  the  carpo-meta car- 
pal articulation  of  the  thumb  and  fifth  finger,  from  an  inch  to  an  inch  and  a 
half,  therefore,  below  the  joint  of  the  wrist.  As  the  integuments  in  this 
situation  are  ample,  and  loosely  attached,  it  is  usually  possible  to  retract 
them  sufficiently,  after  the  first  incision,  by  the  aid  of  light  touches  of  the 
knife,  without  any  regular  dissection ;  when  the  wrist  is  reached,  the  part 
is  held  in  a  position  midway  between  pronation  and  supination,  and  the 

1  Archives  Generales  de  Medecine,  Avril,  1842,  pp.  413,  416. 

2  Traite  de  Chirurgie  d'Armee,  p.  721.    Paris,  1863. 

3  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  Part  Second,  Surgical  volume,  p. 
1019. 

4  Surgery  of  the  Pennsylvania  Hospital,  etc.,  p.  32.  s  Supra. 


638  AMPUTATIONS. 

joint  opened  from  the  radial  side.  Disarticulation  having  been  effected,  the 
cut  vessels  are  secured  (three  or  four  commonly  require  attention),  and  the 
wound  is  closed  transversely. 

Elliptical  Method. — This  is,  upon  the  whole,  probably  the  best  operation 
in  this  particular  situation.  The  lower  segment  of  the  ellipse  may  be  made 
from  either  the  palmar  or  the  dorsal  surface  of  the  hand,  the  former  plan 
being  preferable  as  giving  a  firmer  covering  for  the  ends  of  the  bones.  The 
patient's  hand  being  supinated,  the  surgeon  begins  his  incision,  with  a  strong, 
short-blacled  knife,  about  three-quarters  of  an  inch  below  the  styloid  process 
of  the  radius,  curves  it  downwards  through  the  tissues  of  the  palm  to  a 
point  about  an  inch  lower,  and  then  upwards  again  to  three-quarters  of  an 
inch  below  the  styloid  process  of  the  ulna;  the  hand  is  then  pronated;  and 
the  ends  of  the  first  incision  joined  by  another,  slightly  curved  upwards,  and 
crossing  the  back  of  the  hand  about  half  an  inch  below  the  joint.  The  cuff 
thus  marked  out  having  been  dissected  upwards  as  far  as  necessary,  disarticu- 
lation is  effected  from  the  radial  side,  and  the  operation  terminated  as  in  the 
circular  method.  The  wound  forms  a  curved  cicatrix  on  the  dorsal  side  of 
the  stump,  the  bones  being  covered  by  the  firm  tissues  of  the  palm. 

Flap  Methods. — Of  these,  the  best  is  the  single  palmar  flap  method  (Fig. 
174),  the  flap  being  cut  from  without  inwards,  and  the  result  of  the  operation 

Fig.  174. 


J3/ 

Amputation  at  wrist  by  palmar  flap  method. 

closely  approximating  to  that  of  the  elliptical  method,  as  just  described.  The 
formation  of  a  flap  by  transfixion,  as  practised  by  Lisfranc,  is  attended  with 
much  difficulty,  and  is  now  generally  abandoned.  Another  plan  is  to  employ 
two  flaps — either  lateral  or  antero-posterior — but  I  do  not  recommend  this 
mode  of  procedure.  A  better  plan  (but  still  inferior,  I  think,  to  either  the 
palmar  flap  or  the  elliptical  method),  is  that  of  Dubrueil,  who  makes  a  single 
external  flap,  from  the  tissues  around  the  metacarpal  bone  of  the  thumb. 

Amputation  at  the  wrist  joint  appears  to  be  seldom  performed  either  in 
civil  or  in  military  practice;  I  have  myself  done  it  but  once,  for  gunshot 
injury,  in  a  lad  of  seventeen  who  made  a  good  recovery.  The  death-rate,  as 
shown  by  the  following  Table,  appears  to  be  unduly  high — a  circumstance 


AMPUTATION  OF  THE  FOREARM. 


639 


which  is  due  to  the  large  proportion  of  cases  derived  from  the  records  of  the 
French  army  in  the  Crimea,  in  which  service  amputations  of  all  kinds  proved 
to  be  of  exceptional  gravity. 

Table  showing  the  Mortality  of  Amputations  at  the  \Vrist. 


Authority. 


Malgaigne 
Trelat    . 

Legouest 
Otis 


Aggregates 


Cases. 

Deaths. 

16 

0 

27 

6 

77 

36 

66 

7 

186 

49 

Mortality 

per  cent. 


0.0 
22.2 

46.7 
10.6 


26.3" 


Reference. 


Archives  Gen.  de  Medecine,  Avril,  1842. 
Legouest,  Traite    de    Chirurgie  d'Ariuee, 

p.  722.     Paris,  1863. 
Ibid. 
Med.  and  Surg.  History  of  the  War,  etc. 


Amputation  of  the  Forearm. 

The  best  operation  in  this  situation  is,  under  ordinary  circumstances,  the 
circular,  though  very  good  stumps  may  be  made  by  several  of  the  flap 
methods.  The  amputation  may  be  done  at  any  part  of  the  limb,  the  disad- 
vantages supposed  by  Larrey  to  attend  division  of  the  tendinous  structures 
at  the  lower  part  of  the  forearm,  being  more  imaginary  than  real,  and  there 
being  a  positive  advantage  in  making  the  stump  as  long  as  practicable. 

Circular  Method. — If  the  limb  be  conical,  as  it  usually  is  except  in  very 
thin  persons,  there  may  be  some  difficulty  in  turning  up  the  tegumentary 
cuif,  in  the  circular  operation,  when  it  will  be  advisable  to  slit  the  cuff  upon 
the  ulnar  side.  If  the  tendons  elude  division,  in  amputating  at  the  lower 
part  of  the  limb,  the  knife  may  be  slipped  beneath  them  and  they  may  be  out 
from  within  outwards.  In  sawing  the  bones,  the  limb  should  be  placed  in  a 
position  midway  between  pronation  and  supination,  so  that  both  bones  may 
be  divided  at  the  same  level.  Five  or  six  vessels  commonly  require  ligation, 
in  forearm  amputations,  and  of  these  the  anterior  and  posterior  interosseous 
are  those  that  give  the  most  trouble,  from  their  tendency  to  retract  between 
the  bones,  where  it  may  be  difficult  to  discover  them. 

Flap  Methods. — The  most  brilliant  operation  is  that  made  by  taking 
antero-posterior  flaps  (see  Fig.  150,  page  586),  the  posterior  flap  being  shaped 
from  without  inwards,  and  the  anterior  being  cut  either  in  the  same  way,  or 
by  transfixion,  according  to  the  fancy  of  the  operator.  I  have  more  than 
once  known  consecutive  hemorrhage  to  follow  this  particular  form  of  opera- 
tion, apparently  from  the  interosseous  artery  having  been  divided  obliquely, 
and  as  a  consequence  not  being  properly  secured  by  the  ligature ;  hence  I  have 
been  led  to  prefer,  in  this  situation,  either  the  circular  operation  or  Teak's 
method,  in  which  this  complication  is  more  readily  avoided.  In  practising 
Teale's  method  (Figs.  151,  152,  pp.  587,  588),  care  must  be  taken  to  mark, 
out  the  flaps  by  measurement  before  attempting  to  cut  them,  as  otherwise, 
from  the  conical  shape  of  the  limb,  the  long  flap  will  be  apt  to  be  made  too 
narrow  at  its  distal  extremity.  In  any  of  the  flap  methods,  trouble  may  be 
experienced  from  the  tendons  projecting  beyond  their  sheaths.  Should  this 
occur,  each  tendon  should  be  separatelyseized  with  forceps,  drawn  down,  and 
cut  off  at  as  high  a  point  as  possible. 

1  Omitting  Legouest's  cases,  the  mortality  would  be  about  12  per  cent.,  which  would,  I  believe, 
be  a  fairer  statement. 


640  AMPUTATIONS. 

Mixed  Methods. — Sedillot  makes  superficial  flaps,  and  divides  the  deeper 
tissues  circularly,  while  on  the  other  hand  Richet  makes  a  circular  incision 
through  the  skin  and  fascia,  and  then  forms  muscular  flaps  by  transfixion.  I 
see  no  advantage  in  either  of  these/  proceedings  over  those  more  commonly 
adopted. 

The  mortality  after  amputation  of  the  forearm  is,  as  shown  by  the  Table  on 
page  630, 19.4  per  cent.,  or  about  one  in  five.  It  would  appear  from  Otis's 
statistics,1  that  the  results  are  slightly  more  favorable  for  amputations  at  the 
middle  of  the  forearm  than  for  those  at  either  extremity,  though  among  the 
smaller  number  of  cases  embraced  in  Gorman's  Tables,2  amputations  of  the 
middle  third  proved  the  most  fatal. 


Amputation  at  the  Elbow. 

This  operation  appears  to  have  been  first  performed  by  the  illustrious 
Ambroise  Pare,3  in  the  case  of  a  soldier  whose  arm  became  gangrenous  after  a 
severe  wound  from  an  arquebuse.  The  patient  was  attacked  with  tetanus 
fifteen  days  after  the  operation,  but  eventually  made  a  good  recovery. 

Amputation  at  the  elbow  may  be  performed  by  either  the  elliptical,  the 
circular,  or  one  or  other  variety  of  the  flap  method,  the  first-named  plan  being, 
I  think,  upon  the  whole  the  best. 

Elliptical  Method. — The  lower  segment  of  the  ellipse  should  be  placed 
upon  the  back  of  the  forearm  (see  Fig.  148,  page  583),  where  the  tissues, 
though  not  very  thick,  are  resisting,  and  accustomed  to  support  pressure. 
The  arm  being  semiflexed,  the  point  of  the  knife  is  entered  nearly  an  inch 
below  the  internal  condyle  of  the  humerus,  curved  upwards  over  the  front  of 
the  forearm  nearly  to  the  line  of  the  joint,  and  downwards  again  to  a  point 
an  inch  and  a  half  below  the  external  condyle ;  the  arm  being  then  forcibly 
flexed,  the  ellipse  is  completed  on  the  back  of  the  forearm  by  a  curved  incision 
passing  nearly  three  inches  below  the  tip  of  the  olecranon.  The  cuif  thus 
marked  out  is  rapidly  dissected  upwards  as  far  as  necessary,  when  the  mus- 
cles of  the  front  of  the  forearm  are  cut  about  half  an  inch  below,  and  the 
ulnar  nerve  as  far  above  the  joint,  and  disarticulation  is  effected  from  the 
outer  side.  Some  surgeons  leave  the  olecranon  in  situ,  sawing  across  its  base ; 
but  it  is  apt  to  become  necrosed  under  these  circumstances,  and,  altogether,  I 
see  no  advantage  to  be  gained  by  its  retention.  The  vessels  requiring  liga- 
tion, in  this  operation,  are  the  brachial — or  the  radial  and  ulnar,  according 
to  the  exact  line  of  the  deep  incision — with  some  smaller  anastomotic  branches. 
The  wound  is  closed  transversely,  forming  a  small  curved  cicatrix  in  front  of 
the  bone,  which  is  well  covered. 

Circular  Method. — In  this  operation,  which  also  makes  a  good  stump,  the 
first  incision  is  placed  two  and  a  half  or  three  inches  below  the  line  of  the 
joint.  It  is  better  not  to  cut  through  the  muscles,  but  to  adopt  Velpeau's 
plan,  ami  dissect  up  the  cuff  of  integument  to  the  necessary  height,  and  then 
effeel  immediate  <lis;irticulation.  The  olecranon  should  be  removed  in  this 
as  in  the  elliptical  operation. 

1  Medical  and  Surgical  History,  etc,  Second  Pnrt,  Surgical  volume,  p.  9(57. 

2  Medical  and  Surgical  Reports  of  the  Boston  City  Hospital,  Second  series,  1877,  pp.  299,  300. 

3  Op.  cit.,  t.  ii.  p.  2'Sd. 


AMPUTATION    AT    THE    ELBOW. 


641 


Flap  Methods. — Two  varieties  of  flap  operation  are  practised  in  this  situa- 
tion :  the  anterior  flap  method  of  Brasdor,  Dupuytren,  and  Sedillot,  and  the 
external  flap  method  of  Alphonse  Guerin.     Of  the  two,  the  latter  (Fig.  17o) 

Fig.  175. 


Amputation  at  right  elbow  by  external  flap  method. 

seems  to  me  the  best,  but  either  is,  I  think,  less  desirable  than  the  opera- 
tions already  described.  In  performing  Guerin's  operation,  the  limb  is  held 
in  a  semi-prone  position,  and  the  surgeon,  introducing  the  point  of  his 
knife  in  the  middle  line  of  the  forearm,  about  an  inch  below  the  bend  of  the 
elbow,  cuts  downward  for  a  short  distance  and  then  transfixes  the  limb,  graz- 
ing the  radius  on  the  outer  side  as  he  does  so,  with  the  blade  of  his  instru- 
ment. An  external  flap,  from  two  to  two  and  a  half  inches  in  length,  is  then 
cut  with  a  sawing  motion,  and  the  tissues  on  the  inner  side  of  the  limb  next 
divided  by  a  curved  incision,  convex  downwards.  Disarticulation  is  effected 
by  opening  the  joint  from  its  outer  side. 

The  stump  which  results  from  amputation  at  the  elbow-joint  is  an  admira- 
ble one,  and  the  operation  should,  I  think,  always  be  preferred  to  removal  of 
the  limb  at  a  higher  point.  It  is  somewhat  difficult  to  estimate  the  death-rate 
of  this  operation;  it  does  not  appear  to  have  been  often  resorted  to  in  civil 
practice — I  have  myself  done  it  but  once — and  Malgaigne's  and  Trelat's  com- 
bined statistics,  as  quoted  by  Legouest,  give  but  nine  cases  with  three  deaths. 
Mr.  Bryant  speaks  of  six  successful  cases  in  his  own  practice.  Legouest 
reports  41  vases  from  the  French  army  in  the  Crimean  war,  with  21  deaths, 
but  Chenu  (as  quoted  by  Otis)1  gives  the  figures  for  the  same  service  as  T!» 
cases  with  52  deaths.  The  same  writer  tabulates,  in  all,  133  elbow  amputa- 
tions for  gunshot  injury  with  101  deaths — a  frightful  mortality  of  nearly  76 
per  cent.  But,  on  the  other  hand,  39  terminated  cases  in  the  late  war  in  this 
country,  gave  but  3  deaths,  or  less  than  8  per  cent. 

1  Medical  and  Surgical  History,  etc.,  Part  Second,  Surgical  volume,  p.  910  (Note"). 
VOL.  I. — 41 


G42 


AMPUTATIONS. 


Amputation  of  the  Arm. 

The  humerus  is  placed  so  nearly  in  the  middle  of  the  arm,  that,  in  this 
situation,  an  excellent  covering,  both  of  skin  and  muscle,  can  be  obtained 
by  any  mode  of  amputating  that  the  surgeon  happens  to  fancy.  My  own 
preference,  in  arm  amputations,  is  for  the  circular  operation,  plain  or  modi- 
fied, or  for  the  oval  method.  The  arm,  however,  is  often  considered  the 
typical  locality  for  the  employment  of  the  double  flap  method,  and  I  have 
myself,  on  more  than  one  occasion,  adopted  with  advantage  the  rectangular 
flap  method  of  the  late  Mr.  Teale.  If  the  arm  is  to  be  amputated  near  the 
shoulder,  there  may  not  be  sufficient  space  for  the  adjustment  of  the  tourni- 
quet in  the  usual  manner.  Under  these  circumstances,  if  the  limb  be  drawn 
out  at  a  right-angle  with  the  body,  so  as  to  make  the  head  of  the  humerus 
project  into  the  armpit,  the  axillary  artery  may  be  readily  controlled  by 
applying  a  rather  thick  and  broad  compress,  and  placing  the  tourniquet 
plate  over  the  acromion  process  of  the  scapula ;  or  compression  may  be  made 
upon  the  subclavian  artery,  where  it  crosses  the  first  rib,  by  means  of  a 
wrapped  key  entrusted  to  a  careful  assistant. 

Circular  Method. — This  is  the  operation  to  which  I  give  the  preference  in 
amputating  at  or  below  the  middle  of  the  arm.  (See  Fig.  146,  page  581.) 
If  the  limb  be  slender,  sufficient  retraction  of  the  skin  can  ordinarily  be 


Amputation  of  loft  arm  by  oval  or  Guthrie's  method. 

obtained  without  formally  dissecting  and  turning  up  the  cuff,  but  under 
opposite  circumstances  this  must  bo  done,  and  it  will  then  be  convenient  to 
slit  the  cull*  by  a  longitudinal  incision  on  the  outer  side.  When  the  muscles 
are  divided,  it  will  be  found  that  the  biceps  retracts  much  more  than  the 
others;  hence,  unless  this  have  been  purposely  cut  long,  a  second  sweep  of  the 
knife  should  be  made,  to  insure  that  all  are  severed  upon  the  same  level.    Six 


AMPUTATION  AT  THE  SHOULDER.  643 

or  seven  ligatures  are  usually  required  in  a  primary,  and  sometimes  as  many 
as  fifteen  or  even  more,  in  a  secondary  amputation  in  this  locality.  The 
possible  occurrence  of  a  high  division  of  the  brachial  artery  must  always  be 
borne  in  mind. 

Oval  Method. — This,  which  is  sometimes  known  as  Guthrie's  method,  is 
particularly  adapted  for  amputations  in  the  upper  part  of  the  arm — above 
the  insertion  of  the  deltoid  muscle.  The  point  of  the  oval  {en  raquette)  is 
placed  upon  the  outer  side  of  the  arm  (Fig.  176),  beginning  about  two  inches 
below  the  acromion  process  of  the  scapula ;  the  lateral  branches  are  slightly 
curved,  with  their  convexity  outwards  and  downwards,  and  the  posterior 
branch  is  usually  made  first ;  the  base  of  the  oval,  which  is  placed  on  the 
inner  side  of  the  arm,  and  in  forming  which  the  main  artery  is  divided  trans- 
versely, may  be  cut  either  by  transfixion  or  without  inwards,  according  to  the 
preference  of  the  operator.  This  operation  is  easily  executed,  and  affords  an 
admirable  stump. 

Flap  Methods. — Sabatier  employed  a  single,  square,  external  flap ;  Ver- 
male,  double  lateral  flaps ;  and  Langenbeck  and  Klein,  double  antero-posterior 
flaps.  Sedillot  employs  his  favorite  "mixed  method,"  making  superficial 
lateral  flaps  by  transfixion,  and  dividing  the  muscles  circularly.  Teale's  and 
Lister's  methods  are  also  perfectly  applicable  in  this  situation.  The  chief 
precaution  to  be  observed  in  amputating  by  any  of  the  flap  methods,  is  to 
make  sure  that  the  musculo-spiral  nerve  is  completely  divided  before  apply- 
ing the  saw.  Provided  that  enough  tissue  has  been  preserved  to  make  a  good 
covering  for  the  bone,  the  surgeon  can  hardly  fail  to  obtain  a  satisfactory 
stump,  by  whatever  method  he  may  employ. 

The  mortality  after  amputation  through  the  arm,  as  shown  by  the  Table 
on  page  630,  is  28.4  per  cent.,  or  about  two  in  seven.  Special  attention  was 
directed  by  the  late  Dr.  Otis1  to  the  exceptional  gravity  of  amputations  in  the 
lower  third  of  the  arm,  in  which  situation  he  found  the  death-rate  of  the 
operation  to  be  35.2  per  cent.,  as  compared  with  one  of  22.6  per  cent,  for  the 
upper  third,  and  one  of  only  19.6  per  cent,  for  the  middle  third  of  the  limb. 
This  remarkable  difference,  for  which  no  adequate  explanation  has  yet  been 
suggested,  is  still  more  observable  in  Gorman's  statistics,  derived  from  civil 
practice,2  in  which  the  respective  death-rates  were  22.7  percent,  for  the  wpp*  ft 
21.  -f-  per  cent,  for  the  middle,  and  no  less  than  45.4  per  cent,  for  the  lower  third 
of  the  arm. 

Amputation  at  the  Shoulder. 

This  operation  was  described  by  the  ancients,  but  does  not  appear  to  have 
been  actually  put  in  practice  until  the  early  part  of  the  eighteenth  century, 
unless  we  recognize  as  a  shoulder-joint  amputation  the  famous  case  of  gan- 
grene, recorded  by  the  Abbe  de  la  Roque,3  in  which,  when  about  to  saw 
through  the  humerus,  the  surgeon  found  the  bone  loose,  and  pulled  it  out 
of  its  socket.  It  is  uncertain  to  whom  the  credit  of  first  having  intentionally 
performed  a  shoulder-joint  amputation  actually  belongs,  the  younger  Le  Bran4 
and  the  younger  Morand5  having  both  claimed  it  for  their  respective  fathers. 

1  Medical  and  Surgical  History,  etc.,  Part  Second,  Surgical  volume,  pp.  739,  806,  823. 

2  Medical  and  Surgical  Reports  of  the  Boston  City  Hospital,  Second  series,  1877,  pp.  292-297. 

3  Journal  de  M^decine,  1686  ;  Velpeau,  op.  cit.,  t.  ii.  p.  448. 
*  Traite  des  Operations  de  Chirurgie,  p.  571.     Paris,  1742. 

6  Opuscules  de  Chirurgie,  t.  ii.  p.  212.     Paris,  17U8. 


644 


AMPUTATIONS. 


Le  Dran's  operation,  which  was  done  in  1715,  certainly  excited  the  most 
attention,  for  it  is  fully  described  by  Garengeot1  and  La  Faye,2  who  give  no 
account  of  Morand's  case,  though  in  his  notes  to  Dionis,3  La  Faye  undoubtedly 
attributes  to  the  latter  the  priority.  This  operation  has  been  performed  in  a 
great  variety  of  ways — Sedillot  enumerates  at  least  twenty,  Velpeau  thirty, 
and  Lisfranc  thirty -six — but  I  shall  describe  only  three  methods :  the  oval, 
or  Larrey's;  the  external  flap  method,  or  Dupuytren's;  and  the  antero-posterior 
flap  method,  or  that  of  Lisfranc. 

Oval  Method. — The  circulation  being  controlled  by  compressing  the  sub- 
clavian artery  upon  the  first  rib  with  a  wrapped  key,  boot-hook,  or  tourni- 
quet handle,  the  point  of  a  strong  and  not  very  large  knife  is  introduced  below 

and  a  little  in  front  of  the  acro- 
Fig._i77.  mion  process  of  the  scapula,  and 

a  deep  incision  is  made  in  a  longi- 
tudinal direction,  and  reaching 
about  an  inch  and  a  half  below 
the  neck  of  the  humerus,  the 
length  of  the  first  cut  being  thus 
about  three  inches.  (Fig.  177.) 
From  about,  or  a  little  below,  the 
middle  of  this  incision,  the  knife 
is  then  carried  obliquely  down- 
wards in  front  and  behind,  making 
the  lateral  branches  of  the  oval, 
which  branches,  if  the  limb  be 
muscular,  should  be  somewhat 
curved,  with  their  convexity  down- 
wards. These  lateral  incisions  (of 
which,  if  the  circulation  be  well 
controlled,  the  posterior  should  be 
made  first,  but  otherwise  the  an- 
terior, on  account  of  the  large  size 
of  the  posterior  circumflex  artery) 
should  terminate  at  the  points  at 
which  the  anterior  and  posterior  axillary  folds  end  in  the  tissues  of  the  arm. 
The  lips  of  the  wound  being  then  loosened  from  the  bone  by  a  few  rapid 
strokes  of  the  knife,  the  surgeon  proceeds  to  effect  disarticulation,  first  rotat- 
ing the  arm  forcibly  outwards  while  he  divides  the  subscapular  muscle  which 
is  thus  rendered  tense,  next  cutting  through  the  capsule  of  the  joint  and  the 
tendon  of  the  long  head  of  the  biceps,  and  finally,  while  the  arm  is  forcibly 
rotated  inwards,  severing  the  infra-spinatus  and  the  supra-spinatus  muscles, 
and  the  teres  minor.  The  knife  is  then  slipped  crosswise  behind  the  neck  of 
the  bone,  and  at  the  same  moment  an  assistant  grasps  the  axillary  artery  be- 
hind the  knife,  the  vessel  being  always  found  in  the  first  muscular  interspace 
from  the  anterior  axillary  fold;  the  lateral  incisions  are  then  connected  by  a 
transverse  cut  through  the  tissues  of  the  arm,  from  within  outwards.  The 
vessels  are  then  quickly  tied,  the  brachial  and  the  subscapular  arteries  being 
the  largesl  which  require  attention,  and  the  sides  of  the  oval  are  brought  to- 
gether so  as  to  make  a  linear  wound,  the  direction  of  which  corresponds  with 
tin-  long  axis  of  the  patient's  body.     The  appearance  of  the  stump  resulting 


Amputation  at  right  shoulder  by  oval,  or  Larrey's  method. 


1  Traitfi  dea  Operations  de  Chirurgie,  t.  Hi.  p.  4f>6.     Paris,  1731. 

2  M6moirea  de  I'Aoadfimie  Royale  de  Chirurgie  (an  1740),  t.  ii.  p.  166. 

3  Cours  d'Op6rations  <1<;  Chirurgie,  p.  758.     Paris,  1740. 


Paris,  1819. 


AMPUTATION    AT    THE    SHOULDER. 


645 


from  an  amputation  by  this  method  is  seen  in 
Fig.  178,  from  a  photograph  of  a  lad  under  my 
care  many  years  ago  at  the  Episcopal  Hospital. 

Air.  Spence  has  modified  this  operation  by 
making  the  first  (longitudinal)  incision  much 
longer,  as  if  for  excision  of  the  caput  humeri,  and 
making  the  branches  of  the  oval  more  nearly 
transverse  than  in  Larrey's  method. 

External  Flap  Method. — This  method  was 
first  described  in  print  by  M.  Grosbois,  who 
claimed  it  as  his  own  in  a  thesis  published  in 
1803,  but  it  is  believed  by  Velpeau,  Sedillot,  and 
other  French  authorities,  to  have  really  originated 
with  Dupuytren,  whose  name  it  commonly  bears, 
and  who,  we  are  told,1  practised  it  with  "  great 
dexterity,"  on  the  occasion  of  the  "  concours"  for 
the  chair  of  operative  surgery  (February  15, 
1812).2  It  is  a  modification  of  the  early  opera- 
tion of  Le  Dran  and  La  Faye.  The  principal 
flap  is  an  external,  or,  more  strictly,  a  postero- 
external one,  which  embraces  the  thickness  of  the  deltoid  muscle  (Fig.  179). 
Grasping  this  part  with  his  left  hand,  the  surgeon  enters  the  point  of  his 

Fig.  179. 


Result  of  shoulder-joint  amputation 
by  Larrey's  method. 


Amputation  at  left  shoulder  by  external  flap,  or  Dupuytron's  method. 

knife  about  an  inch  in  front  of  the  acromion  process  of  the  scapula,  and 
pushing  it  directly  across  the  joint  and  its  capsule,  brings  it  out  at  the  pos- 
terior axillary  fold  ;  the  knife  is  then  made  to  cut  at  first  directly  down- 
wards, and  then  outwards  and  backwards,  with  a  sawing  movement,  form- 
ing a  large  flap  which  is  taken  in  charge  and  held  out  of  the  way  by  an 


1  Dictionnaire  des  Sciences  Medicales,  t.  i.  p.  496.     Paris,  1S12. 

2  Id.  op.,  Biographie  Medicale,  t.  iii.  p.  556.     Paris,  1821. 


646 


AMPUTATIONS. 


Fig.  180.  assistant.   Disarticulation  is  then  effected 

as  in  the  oval  operation,  by  rotating  the 
arm  successively  inwards  and  outwards 
so  as  to  render  the  muscles  tense  before 
they  are  cut,  and  the  operation  is  termi- 
nated by  slipping  the  knife  behind  the 
bone,  and  cutting  a  short  flap  which  con- 
tains the  brachial  artery.  The  same 
precautions  against  hemorrhage  should 
be  observed  here  which  were  described 
in  the  account  of  Larrey's  operation. 

A  modification  and,  I  think,  an  im- 
provement of  this  method,  originally 
practised  by  Cline,  and  first  described  in 
this  country  by  Dr.  J.  A  Smith,  of  New 
York,  in  a  letter  to  Dorsey,1  consists  in 
cutting  a  deltoid  flap  of  curved  outline 
from  without  inwards,  then  disarticu- 
lating, and  finally  completing  the  opera- 
tion in  the  way  already  described.  Fig. 
180  shows  the  appearance  of  a  stump  re- 
sulting from  this  variety  of  the  operation. 

Result  of  shoulder-joint  amputation  by  Dupuy-  .  _-,  ,  , 

tren's  method.  ANTERO-POSTERIOR      I  LAP      METHOD. 

This,  which  is  known  as  Lisfranc's 
operation,  gives  a  resultihg  wound  not  unlike  that  obtained  by  the  oval 
method,  to  which,  however,  it  seems  to  me  to  be  inferior.  It  is  described 
by  its  inventor  as  his  second  method.2  Supposing  that  it  is  the  left  arm 
which  is  to  be  removed,  the  surgeon,  causing  it  to  be  held  three  or  four 
inches  away  from  the  body,  seizes  the  shoulder  with  his  left  hand,  and  with 
his  right  introduces  a  long  knife  on  the  outer  side  of  the  posterior  fold  of 
the  axilla,  in  front  of  the  tendons  of  the  latissimus  dorsi  and  teres  major, 
the  blade  of  the  knife  being  pushed  along  the  posterior  surface  of  the  hume- 
rus and  its  edge  being  directed  outwards  and  forwards.  The  knife  is  steadily 
thrust  onwards  until  its  point  reaches  the  head  of  the  humerus,  when  the 
hand  is  first  raised  (to  clear  the  head  of  the  bone),  then  slightly  depressed, 
and  finally  raised  again  and  carried  outwards,  till  the  point  is  beneath  the 
triangular  space  which  exists  between  the  caput  humeri  and  the  acromion 
and  coracoid  processes.  Counter-puncturation  is  next  effected  by  thrusting 
the  point  of  the  instrument  through  the  skin,  and  a  posterior  or  more 
strictly  a  postcro-external  flap,  extending  two  or  three  inches  below  the  joint, 
is  then  cut  from  without  inwards.  This  flap  is  held  out  of  the  way  by  an 
assistant,  while  the  surgeon  slips  the  knife  around  the  head  of  the  bone  from 
behind  forwards,  and  then  cuts  an  anterior  or  antero-internal  flap,  another 
assistant  grasping  the  artery  before  it  is  divided,  as  in  Larrey's  method.  In 
amputating  the  right  arm,  the  anterior  flap  may  be  cut  first,  if  the  surgeon  is 
ambidextrous,  but  it  is  better  to  use  the  right  hand,  standing  behind  the 
patient,  and  making  the  posterior  flap  by  transfixion  from  above  downwards. 

Amputation    at   the  shoulder-joint  is   in   appearance  a  most    formidable 
operation,  and  yet  its  results  are  upon  the  whole  fairly  successful.     The 

1  Elements  of  Surgery,  etc.     By  John  Syng  Dorsey,  M.D.,  2d  edit.,  vol.  ii.  p.  309.      Philadel- 
phia. 1818. 

2  Precis  de  Medeeine  Operatoire,  t.  ii.  p.  186. 


AMPUTATION  ABOVE  THE  SHOULDER. 


647 


following  Table  shows  the  mortality  of  the  operation  according  to  different 
authorities. 

Table  showing  the  Results  of  Amputation  at  the  Shoulder-joint. 


Authority. 

Oases. 

Deaths. 

Mortality 
per  cent. 

Reference. 

Malgaigne 

13 

10 

76.9 

Arch.  Gen.  de  Medecine,  Avril,  1S42,  p. 

409. 

Trelat 

27 

17 

62.9 

Legouest,    Chirurgie   d'Arniee,    p.    725. 
Paris,  1863. 

Legonest   . 

207 

135 

65.2 

Ibid. 

Macleod     . 

173 

69 

39.8 

Surgery  of  the  Crimean  War,  p.  346. 
Phila.,  1862. 

Otis  .... 

841 

246 

29.2 

Surgical  History  of  the  War,  Part  Second, 
pp.  468,  613. 

Spence 

27 

9 

33.3 

Lectures  on  Surgery,  vol.  ii. ;  Med.  Times 
and  Gaz.,  1875,  1876  ;  Edin.  Med.  Jour- 
nal, 1879. 

Golding-Bird     . 

11 

4 

36.3 

Guy's  Hosp.  Reports,  Third  series,  vol. 
xxi.  p.  260. 

Butlin  and  Macready 

7 

3 

42.8 

St.  Bartholomew's  Hosp.  Reports,  vol. 
xiv.  p.  114. 

Morton 

30 

9 

30.0 

Surgery  of  the  Pennsvlvania  Hospital,  p. 
32.     Philadelphia,  "l880. 

Chadwick. 

26 

11 

42.3 

Boston  Med.  and  Surg.  Journal,  May  1, 
1871. 

Gorman     . 

20 

8 

40.0 

Med.  and  Surg.  Reports  of  Boston  City 
Hospital,  Second  series,  p.  292. 

Author1     . 

5 

2 

40.0 

Supra,  page  612. 

Aggregates     . 

1387 

523 

37.7 

Comparing  these  figures  with  those  given  in  the  Table  on  page  630,  it  is 
seen  that  the  death-rate  of  shoulder-joint  amputation,  which  is  less  than  two 
in  five,  is  not  much  greater  than  that  of  amputation  of  the  leg,  and  very 
much  less  than  that  of  amputation  of  the  thigh. 


Amputation  above  the  Shoulder. 

This  operation,  which  consists  in  removing  at  the  same  time  the  entire  arm 
together  with  part  or  all  of  the  scapula,  and  perhaps  a  portion  of  the  clavicle, 
appears  to  have  been  first  performed  by  Cuming,  in  1808,  though  the  famous 
case  of  the  miller,  Samuel  Wood,  whose  arm  and  scapula  Avere  torn  off  by  a 
rope  becoming  wound  around  his  limb,  and  who  recovered  without  any  bad 
symptoms,  occurred  in  1737,  and  had  long  been  familiar  to  surgeons.2  Xo 
universally  applicable  directions  can  be  given  for  the  performance  of  this 
operation,  the  surgeon,  in  cases  of  injury,  being  compelled  to  use  for  his  flaps 
whatever  tissues  are  sufficiently  sound  for  the  purpose,  and  the  lines  of  in- 
cision varying,  in  operations  for  tumors  of  the  part,  in  accordance  with  the 
size  and  shape  of  the  particular  growth  concerned.  Lisfranc's  advice  appears 
to  be  judicious;  that  the  arm  should  be  first  disarticulated,  and  the  axillary 
vessels  secured,  and  that  the  scapula  should  be  removed  subsequently.  This 
bone  may  be  readily  exposed  by  either  a  crucial  or  a  T-shaped  incision,  and 
its  detachment  effected,  as  advised  by  Fergusson  and  Pollock,  by  cutting 
from  below  upwards.     Separation  from  the  clavicle  may  be  accomplished 

1  Besides  the  five  cases  tabulated  above,  I  have  twice  (unsuccessfully)  amputated  at  the  shcul- 
der-joint  synchronously  with  other  major  amputations.      (See  Table  on  page  592. J 

2  Cheselden,  Anatomical  Tables,  Tab.  xxxviii.  p.  43.     Boston,  1796. 


648 


AMPUTATIONS. 


Fig.  181.  either  with  cutting  pliers  or  with   a 

chain  saw.     (Fig.  181.) 

The  gravity  of  the  operation  varies, 
of  course,  with  the  extent  of  bone  re- 
moved ;  if  this  be  limited  to  the 
acromion,  the  case  is  but  little  more 
dangerous  than  an  ordinary  shoulder- 
joint  amputation,  but  if  the  whole  or 
greater  part  of  the  scapula  be  taken 
away,  the  risk  is  very  much  increased. 
Statistical  writers  have  very  com- 
monly confused  this  operation  with  that 
of  excision  of  the  scapula,  either  without 
interference  with  the  arm,  or  subse- 
quent to  previous  amputation.  This  operation  will  be  described  in  a  future 
volume.  The  annexed  Table  contains  a  summary  of  fifty-one1  cases  to  which 
I  have  references,  which  are  properly  designated  as  amputations  above  the 
shoulder. 


Table  of  Amputations  above  the  Shoulder. 


No. 

Operator. 

Result. 

No. 

Operator. 

Result. 

No. 

Operator. 

Result. 

1 

Asiari 

Cured 

19 

Hamilton 

Cured 

37 

Parise 

Died 

2 

Bland 

c  < 

20 

Hay  ward 

it 

38 

Pirondi 

" 

3 

Bower 

" 

21 

Hendry 

" 

39 

Ross 

Cured 

4 

Brice 

if 

22 

Herr 

Died 

40 

Soupart 

" 

5 

Buchanan 

Died 

23 

Hunter 

" 

41 

Syme 

" 

6 

Busch 

Cured 

24 

Jackson 

" 

42 

Tirifahy 

" 

7 

Charles 

" 

25 

Jessop 

Cured 

43 

Twitchell 

l  L 

8 

Clot 

it 

26 

Langenbeck 

Died 

44 

Watson 

" 

9 

Crosby 

a 

27 

Lewis 

" 

45 

Wheelhouse 

" 

10 

Cuming 

" 

28 

Lund 

Cured 

46 

Whishaw 

" 

11 

Esmarch 

" 

29 

McClellan 

" 

47 

Wood 

(( 

12 

Fayrer 

Died 

30 

McGill 

Died 

48 

Id. 

U 

13 

Fergusson 

Cured 

31 

Macleod 

" 

49 

Young 

it 

14 

Id. 

Died 

32 

Mussey 

Cured 

50 

Surg,  at  Penn. 

it 

15 

Gaetani  Bey 

Cured 

33 

Niepce 

" 

Hospital 

16 

Gilbert 

" 

34 

O'Grady 

(< 

51 

Surg,  referred 

(1 

17 

Gross 

Died 

35 

Parise 

(i 

to  bv  Dr.  Otis 

18 

Gund  rum 

Cured 

36 

Id. 

<< 

The  above  51  cases  gave  38  recoveries  and  13  deaths,  a  mortality  of  only 
25.5  per  cent.  There  are  besides  at  least  14  cases  on  record  in  which  recovery 
has  followed  accidental  avulsion  of  the  arm  and  part  or  all  of  the  scapula,2 
so  that  if  we  should  hike  these  figures  without  allowance,  we  would  conclude 
that  the  operation  was  really  one  of  little  risk.  It  is  at  least  sufficiently  suc- 
cessful to  justify  the  surgeon  in  resorting  to  it  in  suitable  cases. 

1  Velpean  says  that  Larrey  did  this  operation  "  several  times,"  and  "more  than  once"  with 
success.     (Nouveaux  Elements  de  Medecine  Operatoire,  t.  ii.  p.  465.) 

2  Dr.  Stephen  Rogers,  of  New  York,  collected  twelve  cases,  in  papers  in  the  American  Journal 
of  the  Medical  Sciences  for  October,  1868,  and  the  New  York  Medical  Journal  for  December,  1870. 
A  thirteenth  ease,  recorded  by  Kathaletzky,  is  noted  in  the  London  Medical  Record  for  Dec.  17, 
I  -7::,  and  a  fourteenth  is  reported  by  Dr.  Ellis-Jones,  a  Welsh  surgeon,  in  the  Lancet  for  Aug. 
20,  1881. 


AMPUTATIONS    OF    THE    TOES. 


649 


SPECIAL  AMPUTATIONS  OF  THE  LOWER  EXTREMITY. 


Amputations  of  the  Toes. 

Amputation  through  the  Phalanges  of  the  toes  is  very  seldom  resorted 
to,  it  being  almost  always  better  to  disarticulate  through  the  interphalangeal  or 
metatarso-phalangeal  joint.  If  the  operation  were  thought  necessary,  it  could 
be  conveniently  done  by  cutting  antero-posterior  flaps  from  without  inwards, 
and  dividing  the  bone  with  strong  cutting  pliers. 

Amputation  at  any  of  the  Interphalangeal  Joints  is  best  done  by  the 
plantar  flap  method,  as  in  the  case  of  the  fingers.  The  joint  is  opened  from 
the  dorsal  surface,  and  the  nap  formed,  after  disarticulation,  by  cutting  from 
within  outwards. 


Fig.  182. 


Amputation  of  a  Toe  at  its  Metatarso-phalangeal  Joint  is  more 
often  required  than  either  of  the  operations  described 
above.  It  may  be  done  by  either  the  lateral  flap  or 
the  oval  {en  raquette)  method  (Fig.  182),  the  latter 
plan  being  the  best.  The  most  important  point  to  be 
remembered  is  that  the  interdigital  web  is  placed 
about  half  way  between  the  joint  and  the  extremity 
of  the  toe,  and  that  hence  the  articulation  is  situated 
higher  than  it  appears  to  be.  The  point  of  the  oval 
should  invariably  be  placed  upon  the  dorsum  of  the 
foot — even  in  the  case  of  the  great  and  fifth  toes — 
so  that  the  cicatrix  may  not  be  exposed  to  friction 
from  the  shoe.  The  knife  is  entered  from  half  to 
three-quarters  of  an  inch  above  the  joint,  and  made 
to  cut  first  in  a  longitudinal  direction  to  the  line  of 
articulation,  and  then  carried  obliquely,  first  on  one 
side  and  then  on  the  other,  to  the  edge  of  the  inter- 
digital web,  thus  forming  the  branches  of  the  oval, 
which  are  eventually  joined  by  a  transverse  incision 
across  the  plantar  surface.  The  tissues  being  dis- 
sected a  little  upwards  from  the  bone,  disarticulation 
is  effected  by  forciby  flexing  the  toe  and  cutting  the 
extensor  tendon  transversely,  and  then  severing  the 
ligaments.  The  wound  is  closed  so  as  to  make  an 
antero-posterior  scar,  protected  from  injury  by  the 
adjoining  toes. 

In  amputating  the  great  toe,  care  must  be  taken  to 
keep  the  incisions  low,  so  as  to  provide  ample  cover- 
ing for  the  head  of  the  metatarsal  bone  which  is  apt 
to  project  in  a  troublesome  manner;  it  is  sometimes 
recommended  that  it  should  be  cut  oft'  with  strong 
forceps,  but  its  removal  is  undesirable  as  it  furnishes 
a  very  important  point  of  support  for  the  arch  of  the  foot. 


Amputation  of  toe  by  oval 
method. 


650 


AMPUTATIONS. 


Amputation  of  all  the  Toes  Simultaneously  may  be  effected  by  the 
■plantar  flap  method  of  Lisfranc,  or  by  the  somewhat  more  complicated  pro- 
cedure of  Dubrueil.  In  the  former,  the  surgeon  applies  the  thumb  and  index 
finger  of  his  left  hand  so  as  to  mark  the  metatarso-phalangeal  articulations 
of  the  fifth  and  great  toes,  and  then  with  a  narrow-bladed  knife  makes  a 
curved  incision,  somewhat  convex  downwards,  beginning  (for  the  right  foot) 
over  the  posterior  part  of  the  first  phalanx  of  the  fifth,  and  for  the  left  foot 
over  the  corresponding  part  of  the  great  toe.  This  flap  being  slightly  dis- 
sected upwards,  each  toe  is  separately  disarticulated,  by  dividing  its  extensor 
tendon  and  articular  ligament,  and  the  surgeon  then,  slipping  the  knife  below 
the  toes,  which  are  raised  for  the  purpose,  cuts  a  plantar  flap  of  sufficient  size 
from  within  outwards.  It  is  usually  advised  that  the  plantar  flap  should 
have  been  first  marked  out  by  a  deep  incision  corresponding  to  the  groove  at 
the  roots  of  the  toes. 

Dubrueil's  operation  resembles  Lisfranc's  as  regards  the  mode  of  obtaining 
a  covering  for  the  metatarsal  bones  of  the  four  smaller  toes,  but  he  supple- 
ments the  plantar  flap  by  taking  an  internal  lateral  flap  from  the  side  of  the 
great  toe,  thus  insuring  an  ample  covering  for  its  metatarsal. 

For  my  own  part,  I  would  advise,  as  in  the  case  of  the  fingers,  that  the 
surgeon  should  sacrifice  brilliancy,  and  amputate  each  toe  separately,  by 
either  the  lateral  flap  or  oval  method  as  may  seem  best  in  each  particular 
instance. 


Amputations  of  the  Foot. 


Amputation  of  the  Fifth  Toe  with  part  or  all  of  its  Metatarsal  Bone 
is  best  effected  by  the  oval  (en  raquette)  method,  the  point  of  the  oval  being 

placed  upon  the  dorsum  of 
Fig.  183.  the   foot,  but,  in  order  to 

give  more  room  for  separa- 
tion of  the  bone,  curved 
outwards  as  shown  in  Fig. 
183.  If  part  of  the  meta- 
tarsal only  is  to  be  re- 
moved, the  bone  may  be 
divided  with  a  narrow- 
bladed  or  chain  saw,  or 
with  strong  cutting  pliers; 
if  complete  disarticulation 
is  to  be  effected,  the  bone 
must  be  first  separated  from 
its  attachment  to  the  cu- 
boid, and  then  from  that  to 
the  fourth  metatarsal,  and 
in  doing  this  the  direction 
of  the  articulation  (oblique, 
inwards  and  backwards)  must  be  remembered.  This  amputation  may  also 
be  done  by  the  external  flap  method,  but  the  operation  is  not  to  be  commended, 
as  the  flap  is  long,  narrow,  and  ill-nourished,  and  is  apt  to  slough. 

Amputation  of  the  Great  Toe,  with  part  or  all  of  its  Metatarsal 
Bone,  may  also  be  performed  by  the  oval  (en  raquette)  method,  the  extremity 
of  the  oval  being  in  this  instance  curved  inwards,  from  the  dorsum  of  the  foot 


Amputation  of  fifth  toe  and  metatarsal  by  oval  method. 


AMPUTATIONS   OF   THE   FOOT. 


651 


to  the  edge  of  the  sole,  as  advised  by  A.  Guerin  and  Dubrueil.  The  internal 
flap  method  may  also  be  advantageously  practised  in  this  situation  (Fig.  184), 
a  fleshy  flap  being  first  raised 
from  the  inner  side  of  the  foot, 
and  replaced  after  disarticula- 
tion. The  surgeon  introduces 
a  strong  and  rather  short  knife 
on  the  dorsal  surface,  on  a  level 
with  the  tarso-metatarsal  joint 
and  between  the  first  and  second 
metatarsal  bones,  and  cuts  di- 
rectly forwards  to  the  ball  of 
the  toe,  then  transversely  out- 
wards and  downwards  in  a  line 
corresponding  to  the  web,  and 
finally  backwards  along  the  in- 
ner side  of  the  sole.  The  flap 
thus  marked  out  is  dissected 
upwards,  keeping  close  to  the  bone,  and  the  knife  is  then  re-entered  between 
the  metatarsals  and  made  to  cut  forwards  through  the  web.  Disarticulation 
is  then  effected  by  attacking  the  joint  from  its  inner  and  dorsal  sides,  and  by 
then  dividing  the  interosseous  ligament  and  the  tendons  of  the  peroneus 
longus  and  tibialis  anticus,  taking  care  not  to  wound  the  dorsal  artery  of  the 
foot.  This  operation  is  readily  performed,  and  affords  a  good  stump,  but 
upon  the  whole  I  am  disposed  to  give  the  preference  to  the  oval  operation  as 
making  a  smaller  wound,  and  one  of  which  the  cicatrix  is  better  placed  as 
regards  the  future  usefulness  of  the  foot. 


Amputation  of  great  toe  and  metatarsal  by  internal  flap  method. 


Amputation  of  two  or  more  Metatarsal  Boxes  is  conveniently  done  by 
the  oral  {en  raquette)  method,  the  point  of  the  oval  being  placed  on  the  dorsum, 
and  beginning  about  half  an  inch  above  the  tarso-metatarsal  joint,  and  its 
branches  diverging  sufficiently  to  include  the  toes  which  it  is  designed  to 
remove.  Beclard  and  Dubrueil  advise  that  more  room  should  be  afforded 
for  disarticulation  by  adding  short  transverse  incisions  on  either  side,  at  the 
upper  end  of  the  point  of  the  oval.  In  all  of  these  operations,  it  will  be  found 
advantageous  to  grasp  the  part  to  be  removed  with  Fergusson's  lion-jawed 
forceps,  held  firmly  in  the  left  hand,  twisting  the  bone  from  side  to  side  so 
as  to  render  tense  the  parts  which  are  to  be  divided. 

I  feel  bound  to  say  that  the  various  operations  on  the  foot,  hitherto 
described,  are  not  often  applicable  in  actual  practice:  the  injuries  in  civil  life 
which  require  amputation  of  the  metatarsal  bones,  usually  involve  the  whole 
anterior  portion  of  the  foot ;  and  the  stumps  which  I  have  examined,  result- 
ing from  these  partial  amputations  after  gunshot  wounds,  have  not  been  as  a 
rule  very  satisfactory. 

Amputation  through  the  Continuity  of  the  Metatarsus. — This  operation 
is  not  unfrequently  required  in  cases  of  injury  involving  the  base  of  the  toes, 
or  of  gangrene  following  frost-bite.  It  may  be  done  by  either  the  circular  or 
the  flap  method,  the  latter  being,  I  think,  preferable  in  this  situation.  Some 
operators  employ  a  single  dorsal  flap,  while  others  (as  Pezerat,  for  instance) 
use  three  flaps — one  from  the  dorsal,  one  from  the  plantar,  and  one  from  the 
inner  side  of  the  foot.  I  think  that  the  best  plan  is  to  make  a  short  dorsal 
and  a  long  plantar  flap,  cutting  both  of  them  from  without  inwards,  and, 
after  sawing  the  bones  on  the  same  level,  bringing  up  the  plantar  flap  so  as 


652 


AMPUTATIONS. 


to  get  a  cicatrix  which  shall  not  be  exposed  to  pressure  from  the  shoe  in 
walking.  This  operation  gives  an  excellent  stump,  and  one  which  seems  to  be 
more  serviceable  than  those  obtained  by  amputation  at  a  point  nearer  the  ankle. 

Amputation  of  the  Entike  Metatarsus. — This  operation  is  said  to  have 
been  formerly  practised  in  a  rude  fashion  by  the  North  American  Indians  as 
a  means  of  preventing  their  prisoners  from  escaping.  It  may  be  performed 
by  either  the  elliptical  or  the  flap  method,  the  latter  being  that  generally 
adopted.  There  are  two  principal  varieties  of  this  operation,  known  respect- 
ively by  the  names  of  Hey  (of  Leeds),  and  of  Lisfranc. 

(1)  Hcy's  amputation  is  practised  by  cutting  a  long  plantar  flap  from  with- 
out inwards,  the  incision  beginning  on  the  outside  at  the  tuberosity  of  the  fifth 
metatarsal  bone,  passing  downwards  to  the  line  of  the  metatarso-phalangeal 
articulations,  then  crossing  the  sole  transversely  in  a  curved  line,  and  passing 
up  again  on  the  inner  side  of  the  foot  to  the  prominence  of  the  scaphoid  bone. 
The  upper  ends  of  this  wound  are  united  by  a  curved  incision,  convex  down- 
wards, across  the  dorsum  of  the  foot,  making  a  short  anterior  flap.  The 
four  outer  metatarsals  are  then  disarticulated  from  the  cuboid  and  external 
and  middle  cuneiform  bones,  and  the  projecting  internal  cuneiform  cut  across 
with  a  small  saw.  This  operation  has  been  modified  by  sawing  across  the 
base  of  the  second  metatarsal  bone,  instead  of  the  internal  cuneiform,  but  the 
latter  was  the  part  divided  in  the  operation  as  originally  performed  in  1799 
by  Mr.  Hey.1  A  similar  operation  is  known  to  French  surgeons  by  the  name 
of  Beclard,  while  Cloquet  has  carried  the  use  of  the  saAv  still  further,  recom- 
mending its  employment  at  any  point  at  which  disarticulation  is  found 
troublesome. 

(2)  Lisfranc's  amputation  differs  from  Hey's  in  being  a  pure  disarticula- 
tion.   (Fig.  185.)     The  surgeon  begins' his  incision  (for  the  right  foot)  at  the 

tuberosity  of  the  fifth  metatar- 
Fig.  185.  sal,  carries  it  across  the  dorsum 

of  the  foot,  in  a  curved  line  with 
its  convexity  downwards,  and 
terminates  it  at  the  tubercle  of 
the  first  metatarsal.  This  incis- 
ion divides  all  the  tissues  down 
to  the  bone,  and,  the  skin  being 
retracted  by  an  assistant,  a  few 
light  touches  of  the  knife  serve 
to  expose  the  line  of  the  tarso- 
metatarsal joints.  Disarticula- 
tion is  then  begun  at  the  outer 
side,  the  fifth,  fourth,  and  third 
metatarsals  being  first  separated, 
and  then  the  first;  the  second, 
which  projects  backwards  be- 
hind the  line  of  the  others, 
being  left  until  the  others  have 
been  freed.  The  point  of  the 
knife  is  then  entered  between 
the  internal  cuneiform  and  tlie  base  of  the  second  metatarsal,  and  made  to 
cut  upwards  so  as  to  divide  the  interosseous  ligament;  the  dorsal  ligaments 
of  the  second  metatarsal  are  next  divided  transversely;  and  finally  disarticu- 
lation  is  completed   by  severing  the  fibrous  bands  on  the  outer  side  of  the 


Arnpntation  of  entire  metatarsus  by  Lbfrauc's  method. 


1  Practical  Observations  in  Surgery,  p.  331.     Philadelphia,  1805. 


AMPUTATIONS    OF    THE    FOOT. 


653 


same  bone.  The  division  of  the  interosseous  ligament  between  the  second 
metatarsal  and  internal  cuneiform  bones  is  the  most  difficult  part  of  this 
manoeuvre,  and  is  best  effected  by  thrusting  the  point  of  the  knife  firmly 
into  the  posterior  part  of  the  first  interosseous  space,  and  then  forcibly  elevat- 
ing the  handle — a  motion  which  is  described  by  French  writers  as  the  tour 
de  maitre.  Disarticulation,  which  may  be  greatly  aided  by  pressing  the  an- 
terior part  of  the  foot  firmly  downwards,  having  been  completed,  the  knife 
is  carried  flatwise  below  the  metatarsal  bones,  and  made  to  cut  a  long  plantar 
flap — rather  larger  on  the  inner  than  on  the  outer  side — from  within  out- 
wards. In  order  to  secure  greater  regularity  of  the  plantar  flap,  it  is  a  good 
plan  to  mark  out  its  dimensions  with  the  point  of  the  knife  before  proceeding 
to  cut  it;  or  the  surgeon  may  adopt  Duval's  plan,  and  begin  by  cutting  the 
flap  from  without  inwards,  as  in  Hey's  operation. 

Amputation  at  the  Medio-tarsal  Joint. — This  operation  (Fig.  186)  bears 
the  name  of  Chopart,  although  it  is  no  longer  performed  in  the  way  directed 

Fig.  186. 


Amputation  at  medio-tarsal  joint. 

by  that  surgeon.1  Chopart  made  a  square  anterior  flap  from  the  dorsum  of 
the  foot,  and,  after  disarticulating,  cut  the  posterior  or  plantar  flap  from  with- 
in outwards;  but  most  surgeons,  at  the  present  day,  adopt  Richerand's  and 
Lisfranc's  modification,  making  a  curved  anterior  flap  of  which  the  extremi- 
ties reach  to  the  position  of  the  articulation,  and  many  prefer  to  cut  the 
plantar  flap  from  without  inwards,  a  plan  which  has  the  advantage  of  allow- 
ing the  flap  to  be  more  regularly  shaped  than  when  it  is  cut  in  the  opposite 
direction.  The  object  of  this  operation  is  to  remove  all  of-  the  tarsus  except 
the  os  calcis  and  the  astragalus,  but  it  has  often  happened  that  the  scaphoid 
has  been  left  unintentionally,  without  interfering  at  all  with  the  successful 
result  of  the  procedure,  and,  indeed,  M.  Laborie  and  Mr.  Hancock  advise 
that  it  should  always  be  retained  if  possible,  the  latter  surgeon  sawing  across 
the  cuboid  on  a  corresponding  line.2  In  performing  Chopart's  amputation, 
the  surgeon  grasps  the  anterior  part  of  the  foot  in  his  left  hand,  and  with  a 
strong,  short  knife  makes  a  transverse  incision,  convex  forwards,  over  the 
dorsum,  from  a  point  half-way  between  the  external  malleolus  and  the  tube- 
rosity of  the  fifth  metatarsal  on  the  outside,  to  a  point  about  half  an  inch 
behind  the  prominence  of  the  scaphoid,  on  the  inner  side  of  the  foot.  The 
plantar  flap  extends  from  the  same  points  as  far  forward  as  the  line  of  the 
metatarso-phalangeal  joints.     Disarticulation  is  rendered  more  easy  by  forci- 

1  A  similar  operation  appears  to  have  been  known  to  Fabriciua  Hildanus. 

2  A  similar  operation  is  practised  by  Prof.  Agnew,  of  Philadelphia,  and  by  Dr.  S.  F.  Forbes,  of 
Toledo,  Ohio. 


654 


AMPUTATIONS. 


bly  pressing  the  front  of  the  foot  downwards,  so  as  to  make  the  anterior  liga- 
ments as  tense  as  possible. 

Trouble  is  sometimes  experienced  during  the  after-treatment  of  patients 
who  have  submitted  to  Chopart's  amputation,  from  contraction  of  the  mus- 
cles of  the  calf  drawing  the  heel  upwards,  thus,  when  the  patient  begins 
to  walk,  bringing  the  cicatrix  against  the  sole  of  the  shoe,  and  so  causing 
irritation.  This  contraction  can  usually  be  prevented  by  bandaging  the  leg 
from  above  downwards,  or  by  applying  a  broad  strip  of  plaster  connected  with 
a  weight  and  pulley,  but  division  of  the  tendo  Achillis  may  occasionally  be 
required.  Dubrueil  recommends  the  use  of  a  wedge-shaped  pad  in  the  shoe, 
the  base  of  the  wedge  being  directed  forwards.  Trouble  from  this  source 
is  less  likely  to  be  met  with  when  the  plantar  flap  is  of  ample  dimensions, 
than  when  it  is  somewhat  scanty. 

The  statistics  of  Chopart's  amputation  were  particularly  investigated  by 
the  late  Mr.  Hancock,1  who  found  that  152  terminated  cases  gave  but  11 
deaths,  a  mortality  of  only  7.2  per  cent.,  while  no  less  than  120  of  the  126 
patients  who  recovered  had  useful  limbs.  Larger's  figures,2  from  French 
sources,  are  less  favorable,  38  cases  having  given  14  deaths,  or  36.8  per  cent., 
though  only  half  of  these  were  properly  attributable  to  the  operation. 

Sub-astragaloid  Amputation. — This  operation  appears  to  have  been  sug- 
gested by  Lignerolles,3  though  it  was,  according  to  Hancock,4  first  performed 
by  Textor  in  1841.  The  peculiarity  of  the  operation  consists  in  the  removal 
of  the  whole  foot  with  the  exception  of  the  astragalus.  Lignerolles  and  Vel- 
peau  advised  that  the  surgeon  should  make  two  lateral  flaps,  and  turn  them 
upwards  towards  the  malleoli  before  disarticulating.  Lisfranc  employed  a 
single  dorsal  flap,  and  Malgaigne  a  single  flap  from  the  inner  portion  of  the 
sole.  Verneuil's  method,  which  seems  to  be  the  one  generally  adopted  in 
France,  is  somewhat  differently  described  by  different  writers ;  it  is  essentially 
an  application  of  the  oval  method,  the  point  of  the  oval  being  placed  on  the 

outer  side  of  the  foot,  below  and  be- 
hind the  external  malleolus,  while 
the  base  of  the  oval  crosses  the  inner 
side  of  the  foot  over  the  middle  por- 
tion of  the  internal  cuneiform  bone. 
Nelaton  modified  this  procedure  by 
making  another  angle  at  the  base  of 
the  oval,  thus  really  making  dorsal 
and  plantar  flaps,  the  junction  of 
which  was  made  further  back  upon 
the  outer  than  upon  the  inner  side. 
The  plan  recommended  by  modern 
English  writers,  and  that  which  I 
have  myself  successfully  followed  in 
two  cases  (Fig.  187),  is  to  make  a 
flap  from  the  heel,  as  in  Syme's  ope- 
ration at  the  ankle-joint,  only  some- 
what longer,  with  a  short  anterior 
flap  from  the  dorsum.  As  soon  as 
the  heel-flap  has  been  loosened  as  far  back  as  the  tubercles  of  the  calcancum, 
the  anterior  part  of  the  foot  may  be  cut  away,  and  the  os  calcis  then  grasped 

1  Operative  Surgery  of  the  Foot  and  Ankle-joint,  p.  386.     London,  1873. 

2  Bulletin  do  la   Soeiete   de  < 'hirui'gie  ;  apud  llayem,  Revue  des  Sciences  Medical es,  Oct.  15, 
1880. 

3  Velpeau,  Traitfi  de  Medecine  OpSratoire,  t.  ii.  p.  499.     Paris,  1839.  *  Op.  cit.,  p.  191. 


Sub-astrat,'alniil  amputation  of  foot. 


AMPUTATIONS   OF   THE   FOOT. 


655 


with  the  lion-jawed  forceps,  and  twisted  from  side  to 
side,  while  its  separation  is  completed  by  disarticulat- 
ing it  from  the  astragalus,  and  dividing  the  tendo 
Achillis  and  remaining  attachments  of  the  bone.  If 
the  flaps  are  not  of  ample  dimensions,  the  head  of  the 
astragalus  should  be  removed  with  a  small  saw,  a  step 
which  Hancock  recommends  in  all  cases.  This  opera- 
tion affords  a  most  admirable  stump,  which  has  the 
advantage  over  those  produced  by  Syme's  and  PirogofFs 
methods  that  it  retains  the  motions  of  the  ankle-joint, 
and  thus  allows  an  elasticity  of  gait  in  walking,  which 
would  otherwise  be  absent.  The  appearance  of  the 
stump  resulting  from  this  operation  is  shown  in  Fig. 
188,  from  a  patient  under  my  care,  a  year  or  two  since, 
at  the  University  Hospital. 

Mr.  Hancock1  refers  to  22  cases  of  this  operation  (in- 
cluding one  of  his  own),  at  least  20  of  which  terminated 
successfully.  Larger2  tabulates  21  cases,  of  which  5 
proved  fatal,  only  three  of  these,  however,  as  the  result 
of  the  operation.  Both  of  my  own  cases  resulted  in 
recovery. 

Hancock's  Amputation. — This,  which  may  be  re- 
garded as  a  combination  of  the  sub-astragaloid  with 
PirogofFs  method  (to  be  presently  described),  consists 
in  sawing  through  the  os  calcis  as  in  that  operation, 
and  bringing  the  sawn  surface  in  contact  with  a  trans- 
verse section  of  the  astragalus.  This  is  certainly  a 
very  ingenious  procedure,  and  in  the  case  in  which  Mr. 
Hancock  employed  it,  the  result  was  all  that  could  be 

wished.  I  confess,  however,  that  it  does  not  seem  to  me  to  present  any  ad- 
vantage over  the  ordinary  subastragaloid  operation,  which  has  the  advantage 
of  greater  simplicity. 

Tripier's  Amputation. — This  operation,  which  has  been  suggested  by  M. 
Tripier,  of  Lyons,  may  also  be  looked  upon  as  a  modification  of  the  sub- 
astragaloid method.  The  external  incisions  are  made  as  in  Chopart's  medio- 
tarsal  operation,  and,  the  anterior  part  of  the  foot  having  been  removed,  the 
calcaneum  is  sawn  through  on  a  level  with  the  sustentaculum  tali,  and  on  a 
plane  at  right  angles  to  the  axis  of  the  leg. 

Other  Amputatons  of  the  Foot. — Mr.  Hancock's  suggestion  that,  instead 
of  amputating  at  the  medio-tarsal  joint,  the  scaphoid  should  be  left  with  the 
posterior  portion  of  the  cuboid,  has  already  been  referred  to.  The  same  sur- 
geon, reviving  the  teaching  of  Mayor,  of  Lausanne,  advises  that  the  foot 
should,  for  operative  purposes,  be  looked  upon  as  a  whole,  and  that,  after  the 
formation  of  suitable  flaps,  the  tarsus  should  be  sawn  through  at  whatever 
point  may  be  found  necessary,  without  regard  to  its  articulations.  Acting 
upon  this  suggestion,  I,  in  one  case,  sawed  through  the  scaphoid  bone,  the 
posterior  part  of  which  was  healthy,  and  removed  the  anterior  diseased  sur- 
surface  of  the  os  calcis ;  the  patient  made  an  excellent  recoATery. 

The  results  of  amputations  of  the  toes  and  partial  amputations  of  the  foot 
are  usually  satisfactory.     I  have  met  with  no  fatal  cases  in  my  own  experi- 


Stuinp  from  sub-astragaloid 
amputation. 


>  Op.  cit.,  p.  205. 


2  Loc.  cit. 


656 


AMPUTATIONS. 


ence,  and  the  records  of  British  surgery  and  of  the  late  American  war  show 
a  very  low  rate  of  mortality  ;  but  the  French  statistics  are  much  less  favora- 
ble ;  the  figures  are  shown  in  the  following  Table : — 

Table  showing  Results  of  Amputations  of  the  Toes  and  Partial 
Amputations  of  the  Foot. 


Toes. 

Partial  of  Foot. 

Authority. 

Cases. 

Deaths. 

Mortality 
per  cent. 

Cases. 

Deaths. 

Mortality 
per  cent. 

Eeference. 

Otis      . 

Hancock 

Legouest 
Larger 

790 
370 

6 

70 

0.7 

18.9 

119 

174 

255 

80 

11 
13 

97 
23 

9.2 

7.4 

38.4- 

28.7 

Circular  No.  6.  S.  G.  O.,  1865,  p. 
45. 

Op.  Surgery  of  Foot  and  Ankle- 
joint,  pp.  205,  386. 

Chirurgie  d'Armee,  pp.  726,  731. 

Revue  des  Sciences  Medicales,  Oct. 
15,  1880. 

Aggregates 

1160 

76 

6.5 

628 

144 

22.9 

Amputation  at  the  Ankle. 

Removal  of  the  entire  foot  at  the  ankle-joint  was  somewhat  vaguely  referred 
to  by  Hippocrates,  and  subsequently  by  Fabricius  Hildanus,  and  appears  to 
have  been  occasionally  resorted  to  by  various  surgeons,  among  whom  may  be 
particularly  mentioned  Sedilier,  of  Laval,  Rossi,  and  Baudens  ;  but  the  ope- 
ration did  not  obtain  general  acceptance  as  a  recognized  procedure  until  the 
late  Prof.  Syme,  of  Edinburgh,  introduced  a  new  mode  of  performing  it  in 
the  year  1842.  Rossi  had  employed  two  lateral  flaps,  and  Baudens  a  single 
dorsal  flap,  while  Velpeau  advised  semi-lunar  incisions  over  the  heel  and  in- 
step, the  edges  of  the  wound  being  brought  together  from  before  backwards, 
so  that  its  angles  should  cover  in  the  malleoli,  which,  in  all  of  these  methods, 
were  allowed  to  remain.  Various  modifications  of  Syme's  method  have  been 
suggested  and  practised,  the  most  important  being  those  of  Roux,  Pirogotf, 
Fergusson,  and  Le  Fort. 

Syme's  Amputation. — As  I  quite  agree  with  Mr.  Hancock  and  Mr.  Syme 
himself,  that,  in  estimating  the  value  of  any  particular  operation,  we  should 
take  care  that  the  operation  itself  is  performed  in  the  manner  directed  by  its 
introducer,  and  not  confuse  it  with  the  modifications,  or  so-called  "  improve- 
ments," of  other  surgeons,  I  shall  quote  Mr.  Syme's  own  description  of  his 
mode  of  procedure : — l 

In  performing  the  operation,  the  foot  being  held  at  a  right  angle  to  the  leg,  the 
point  of  a  common  straight  bistoury  should  be  introduced  immediately  below  the  fibula, 
at  the  centre  of  its  malleolar  projection,  and  then  carried  across  the  integuments  of  the 
sole  in  :t  straight  line  to  the  same  level  on  the  opposite  side.  The  operator  having  next 
placed  the  fingers  of  his  left  hand  upon  the  heel,  and  inserted  the  point  of  his  thumb 
into  the  incision,  pushes  in  the  knife  with  its  blade  parallel  to  the  bone,  and  cuts  down 
to  the  osseous  surface,  at  the  same  time  pressing  the  flap  backwards  until  the  tuberosity 
is  fairly  turned,  when,  joining  the  two  extremities  of  the  first  incision  by  a  transverse 
one  across  the  instep,  he  opens  the  joint,  and  carrying  his  knife  downwards  on  each 
side  of  the  astragalus,  divides  the  lateral  ligaments,  so  as  to  complete  the  disarticula- 
tion.    Lastly  the  knife  is  drawn  round  the  extremities  of  the  tibia  and  fibula,  so  as  to 

1  Observations  on  Clinical  Surgery,  p.  47.     Edinburgh,  1861. 


AMPUTATIONS   AT   THE   ANKLE. 


G<37 


expose  them  sufficiently  for  being  grasped  in  the  hand  and  removed  by  the  saw.  After 
the  vessels  have  been  tied,  and  before  the  edges  of  the  wound  are  stitched  together,  an 
opening  should  be  made  through  the  posterior  part  of  the  flap,  where  it  is  thinnest,  to 
afford  a  dependent  drain  for  the  matter,  as  there  must  always  be  too  much  blood  retained 
in  the  cavity  to  permit  of  union  by  the  first  intention.  The  dressings  should  be  of  the 
lightest  description. 

As  already  indicated,  this  operation  (Fig.  189)  has  heen  modified  or  "  im- 
proved" by  various  surgeons,  some  making  the  heel  flap  longer,  and  others 
shorter,  than  directed  by  Mr.  Syme,  and  some  only  dissecting  the  flap  back 

Fiz.  189. 


Amputation  at  ankle  by  Syme's  method. 

to  the  point  of  the  heel,  and  disarticulating  before  dividing  the  tendo  Achillis 
and  completing  the  separation  of  the  os  calcis.  As  regards  the  length  of  the 
flap,  Dr.  J.  A.  Wyeth,  of  Eew  York,  has  proved  by  a  large  number  of  dis- 
sections that  the  main  supply  of  blood  to  the  heel  flap  is  derived  from  the 
calcaneal  branches  of  the  external  plantar  artery,  and  that  hence  a  Ions;  flap 
is  less  likely  to  slough  than  a  short  one :  hence  if  any  deviation  is  to  be  ^made 
from  Mr.  Syme's  lines  of  incision,  it  should  be  in  the  direction  of  lengthening 
the  flap  rather  than  of  abbreviating  it,  Provided,  however,  that  the  knife 
be  kept  close  to  the  bone,  in  separating  the  flap  from  the  calcaneum,  there  is 
not  much  risk  of  impairing  its  vitality.  Syme's  amputation  affords  an  excel- 
lent stump,  covered  with  the  natural  tissues  of  the  heel,  and  capable  of  sus- 
taining the  entire  weight  of  the  patient.  In  some  cases  the  tendo  Aciiillis 
appears  to  acquire  fresh  attachments  to  the  bones  of  the  stump,  and  the 
patient  is  enabled  not  only  to  walk  but  to  run.  The  same  advantage  is 
claimed  for  the  stump  made  by  Pirogoff's  method,  but  the  Syme  stump  is, 
according  to  Prof.  Stephen  Smith,  of  Xew  York,  better  suited  "than  the  other 
for  the  adaptation  of  an  artificial  limb.  A  modification  of  Syme's  method 
which  seems  to  me  to  be  really  an  improvement,  is  that  employed  by  Macleod, 
of  Glasgow,  and  J.  Bell,  of  Edinburgh,  which  consists  in  preserving',  when- 
ever it  is  practicable  to  do  so,  the  periosteal  covering  of  the  calcaneum. 

The  following  Table  shows  the  statistical  results  of  Syme's  amputation,  aa 
given  by  various  authors  : — 


vol.  i. — 42 


658 


AMPUTATIONS. 


Table  showing  the  Results  of  Syme's  Amputation  at  the  Ankle. 


Authority. 

Cases. 

Deaths. 

17 

8 

8 

Mortality 
per  cent. 

Reference. 

Hancock . 
Spence     .     . 

Fayrer     .     . 

219 

107 
12 

7.7 
7.4 

6V.6 

Operative  Surgery  of  Foot  and  Ankle-joint,  p.  152. 
Lectures  on  Surgery,  vol.  ii.  ;  Med.  Times  and  Gaz.,  1875 

and  1876;  Edin.  Med.  Journal,  1879. 
Hancock,  op.  cit.,  p.  155. 

Aggregates 

338 

33 

9.7 

Roux's  Amputation. — In  this  operation,  the  flap  is  derived  mainly  from 
the  inner  side  of  the  foot.  The  surgeon  begins  his  incision  at  the  posterior 
edge  of  the  external  face  of  the  os  calcis,  carries  it  below  the  external  mal- 
leolus, and  then  over  the  dorsum  of  the  foot,  in  a  curved  line,  convex  forwards, 
half  an  inch  below  the  articulation.  This  incision  ends  a  little  in  front  of  the 
internal  malleolus,  and  a  second,  starting  from  the  termination  of  the  first, 
crosses  the  sole  somewhat  obliquely  backwards  to  the  point  whence  the  first 
took  its  origin.  An  irregularly  oval  wound  is  thus  made  with  the  point  of 
the  oval  on'the  outer  side  of  the  foot.  The  malleoli  are  removed  in  this  as 
in  Syme's  operation.  I  have  no  personal  experience  with  this  particular  form 
of  operation,  but  should  not  suppose  that  the  stump  would  be  as  serviceable 
as  that  obtained  by  Syme's  method. 

Pirogoff's  Amputation. — The  peculiarity  of  this  operation  consists  in  the 
removal  of  all  the  foot  except  the  posterior  part  of  the  calcaneum,  which  is 
brought  forward  and  placed  in  apposition  with  the  sawn  ends  of  the  tibia 
and  "fibula,  the  articulating  surfaces  of  the  latter,  with  the  malleoli,  being 
removed  as  in  the  procedure  of  Syme  and  Roux.  The  operation  is  done  as 
follows :  The  surgeon  makes  first  a  somewhat  oblique  incision,  with  an  ante- 
rior convexity,  across  the  plantar  surface,  from  one  malleolus  to  the  other, 
coming  a  little  further  forward  on  the  inner  than  on  the  outer  side,  so  as  to 
avoid  the  posterior  tibial  artery.  The  flap  thus  marked  out  is  dissected  back- 
wards for  about  a  quarter  of  an  inch,  and  the  extremities  of  the  wound  are 
then  united  by  a  second  incision,  also  with  anterior  convexity,  over  the  dorsal 

surface,   and    crossing    the 
Fig.  190.  ankle  in  such  a  way  as  to 

expose  the  joint.  This  be- 
ing opened,  disarticulation 
is  effected,  and  the  surgeon 
then,  slipping  a  narrow- 
bladed  saw,  or  the  blade  of 
a  "  Butcher's"  saw  behind 
the  astragalus  (Fig.  190) 
saws  through  the  os  calcis, 
obliquely  downwards  in  the 
line  of  the  first  incision. 
The  ends  of  the  tibia  and 
''  fibula1  are  next  removed, 
and,  hemorrhage  having 
been  checked,  the  wound  is 
closed  with  sutures.  If 
Amputation  by  pirogoff's  method.  Butcher's  saw  be  used,  the 

1  It  is  somewhat  uncertain  whether  Pirogoff  himself  removes  more  than  the  malleoli  (see  Han- 
cock, op.  cit.,  p.  1(31),  but  it  is  customary  in  England  and  in  this  country  to  remove  the  whole 
articulating  surface. 


AMPUTATIONS  AT  THE  ANKLE.  659 

leg  bones  may  be  divided  from  below  upwards  by  reversing  the  blade  of  the 
instrument.  Any  tendency  to  tilting  of  the  heel  fragment  by  the  action  of 
the  calf-muscles  must  be  overcome  in  the  manner  directed  in  speaking  of  Clio- 
part's  amputation.  Various  modifications  of  this  operation  have  been  sug- 
gested, as  that  the  tibia  and  fibula  should  be  sawn  before  the  calcaneum  ; 
that  the  latter  should  be  sawn  from  below  upwards,  that  it  should  be  sawn 
obliquely,  etc.  Dr.  J.  S.  Wight,  of  Brooklyn,  saws  through  the  os  cal<is, 
and  then  removes  the  foot  and  malleoli  together,  without  disarticulation.  But 
the  most  important  modifications  of  PirogofFs  method  are  those  of  Sir  W, 
Fergusson  and  Prof.  Le  Fort,  which  will  be  presently  described. 

Mr.  Syme  denounced  the  adoption  of  PirogofFs  method  as  "  a  certain  sign 
of  lax  surgical  principle,"  but  other  operators  have  entertained  a  more  favor- 
able view  of  the  Russian  surgeon's  procedure.  While  I  have  myself  preferred 
either  the  original  method  of  Syme  or  the  subastragaloid  operation,  I  have 
seen  most  admirable  stumps  produced  by  Pirogotf 's  mode  of  amputating,  and 
can  entertain  no  doubt  of  its  value.  Its  statistical  results  also  are  very  favor- 
able, as  maybe  seen  by  the  following  figures :  Pirogoff,  in  a  letter  to  Mr. 
Hancock,1  speaks  of  "  nearly  100"  cases  in  civil  practice  in  Russia,  and  00 
during  the  Crimean  war,  and  of  the  latter  says,  "I  only  know  with  certainty 
of  seven  deaths."  0.  Weber  enumerates  40  cases,  and  estimates  the  mortality 
at  15  per  cent.  Fifteen  cases  reported  by  Kestnor,  of  Strasbourg,  appear  to 
have  all  terminated  favorably.  Eighty-one  cases  collected  by  Hancock,  prin- 
cipally from  British  sources,  gave  only  7  deaths,  a  mortality  of  but  8.6  per 
cent.,  and  77  cases  collected  by  Gross  (of  Nancy)  and  Pasquier  gave  only  8 
deaths,  a  mortality  of  10.3  per  cent.  Dr.  A.  Hewson  and  Dr.  Forbes,  of 
Philadelphia,  have  each  performed  the  operation  several  times  with  excellent 
results. 

Fergusson's  Modification  of  PirogofFs  amputation  consists  in  not  interfer- 
ing with  the  malleoli,  unless  they  are  themselves  diseased,  but  thrusting  the 
sawn  end.  of  the  os  calcis  up  between  them.  This  plan  has  also  been  adopted 
by  other  surgeons,  among  whom  I  may  mention  Prof.  Agnew,  of  Philadel- 
phia, and  Dr.  Quimby,  of  New  Jersey.  In  order  to  prevent  retraction  of  the 
heel-flap,  Sir  William  Fergusson  also  recommended  division  of  the  tendo 
Achillis  as  a  preliminary  step  in  the  operation. 

Le  Fort's  Modification  of  PirogotF's  operation  is  performed  as  follows : 
The  external  incisions  are  the  same  as  in  Roux's  modification  of  Syme's  am- 
putation. The  dorsal  flap  is  loosened  and  raised  so  as  to  expose  the  ankle- 
joint,  taking  care,  in  working  at  the  inner  side,  not  to  wound  the  posterior 
tibial  artery.  The  ligaments  which  unite  the  foot  to  the  fibula  are  then 
divided,  with  the  ligaments  between  the  calcaneum  and  the  astragalus,  allow- 
ing the  luxation  of  the  foot  inwards.  The  anterior  portion  of  the~foot  is  next 
cut  away  at  the  medio-tarsal  joint,  and  the  astragalus  seized  with  strong  fi  >r - 
ceps  to  facilitate  its  enucleation.  The  os  calcis  is"  then  depressed,  and  divided 
with  a  narrow-bladed  saw  from  behind  forwards,  so  as  to  remove  all  the  upper 
part  of  the  bone,  beginning  at  the  insertion  of  the  tendo  Achillis.  The  mal- 
leoli and  articulating  surface  of  the  tibia  are  finally  removed,  and  the  sawn 
surfaces  of  bone  placed  in  apposition.  What  is  proposed  to  be  accomplished 
by  this  particular  form  of  operation,  is  to  keep  the  os  calcis  in  a  compara- 
tively normal  position,  and  to  permit  the  patient,  in  walking,  to  receive  pres- 
sure on  the  thick  tissue  of  the  heel,  which  is  accustomed  to  support  it,  rather 
than  on  the  thin  tissue  behind  the  heel,  which  is  apt  to  be  drawn  forwards 
when  the  operation  is  done  by  the  original  method  of  Pirogoff. 

1  Op.  cit.,  p.  184. 


660 


AMPUTATIONS. 


The  results  of  these  various  amputations  at  the  ankle  are  quite  satisfactory. 
The  statistics  of  Syme's  and  PirogofFs  methods  have  already  been  referred  to, 
but  a  more  compendious  view  of  the  subject  can  be  obtained  from  the  follow- 
ing Table : — 


Table  showing  the  Results  of  Amputations  at  the  Ankle. 


Nature  of  operation.  |           s. 

Deaths. 

Mortality 
per  cent. 

Authority. 

Svrue's  method   .       338 
Pirogoff's  method!     273 
Not  specified       .       358 

33 

28 

101 

9.7 
10.2 

28.2 

Hancock,  Spence,  Fayrer. 

Pirogoff,  Weber,  Kestnor,  Hancock,  Gross,  Pasquier. 

Legouest,  Otis,  Larger. 

Aggregates      .       969 

162 

16.7 

Amputation  of  the  Leg. 

Amputation  of  the  leg  may  be  performed  at  any  part  of  the  limb,  the  best 
operation  being,  I  think,  the  circular  or  modified  circular,  in  the  lower  third, 
and  Sedillot's  or  Lee's  flap  method  in  the  middle  and  upper  portions.  As  a 
rule,  the  stump  should  be  made  as  long  as  the  circumstances  of  the  case  will 
permit,  but  we  still  are  occasionally  requested  by  patients  to  amputate  at  what 
used  to  be  called  the  "  point  of  election"  (two  or  three  inches  below  the  tuber- 
cle of  the  tibia),  so  as  to  allow  the  use  of  a  "  peg"  or  "  box  leg,"  without  the 
annoyance  of  the  stump  projecting  backwards. 

Amputation  in  the  Lower  Third  of  the  Leg,  or  the  supra-malleolar 
(sus-malleolaire)  operation  of  French  writers,  is  best  performed  by  the  circular 
method,  the  cuff  of  integument  being  slit  upon  its  outer  (fibular)  side,1  in  order 
to  obviate  trouble  in  turning  it  up  when  the  limb  is  a  conical  one;  or  by 
the  modified  circular  method,  in  which  case  the  skin  flaps  may  be  made  either 
antero-posteriorly  or  transversely,  according  to  the  fancy  of  the  operator.  M. 
Guyon  practises  the  elliptical  method  in  this  situation,  taking  the  lower  seg- 
ment of  the  ellipse  from  the  tissues  covering  the  heel. 

Amputation  in  the  Middle  or  Upper  Third  of  the  Leg  may  be  done  by 
almost  any  of  the  operations  which  have  been  described,  but  the  best,  I 
think,  are  two  varieties  of  the  flap  method,  known  respectively  by  the  names 
of  M.  Sedillot  and  Mr.  Henry  Lee.  Teale's  method  is  less  applicable  in  this 
situation  than  in  the  forearm,  the  long  flap  containing  the  anterior  tibial 
artery,  and  being  very  thin  where  it  overlies  the  tibia,  and  consequently  liable 
to  slough.  The  objections  to  the  ordinary  operation,  in  which  a  large  flap 
is  cut  by  transfixion  from  the  calf,  are  that  on  the  one  hand,  from  its  weight, 
it  is  apt  to  fall  away  from  the  anterior  flap,  and  that  on  the  other  hand,  the 
skin  retracting  more  than  the  muscle,  unless  this  is  retrenched  before  the 
wound  is  closed,  it  is  unduly  compressed  by  the  sutures  which  are  employed, 
and  great  tension  of  the  part,  causing  much  discomfort,  is  almost  sure  to  ensue. 

External  Fiji />  Method,  or  that  of  Sidillot. — This  is  the  operation  which  I  pre- 
fer to  all  others  for  amputation  in  the  upper  part  of  the  leg.  It  is  performed 
as  follows:  the  circulation  having  been  controlled  in  the  ordinary  way,  a 
preliminary  longitudinal  incision  through  the  skin  is  made  along  the  inner 

1  The  operation  known  as  Lenoir's  is  simply  a  circular  amputation  with  the  cuff  slit  in  front 
Instead  <>t'  at  the  outer  si'li-,  as  1  have  advised. 


AMPUTATION   OF   THE   LEG. 


661 


edge  of  the  tibia ;  the  tissues  being  then  drawn  to  the  fibular  side  of  the 
limb,  the  longitudinal  incision  gapes  sufficiently  to  allow  a  slender  catlin  to 
be  introduced  close  to  the  outer  edge  of  the  tibia,  made  to  graze  the  fibula, 
and  to  be  brought  out  posteriorly,  transfixing  the  limb  on  the  outer  side  of 
both  bones.  The  knife  is  then  carried  downwards  close  to  the  bones,  with 
a  sawing  motion,  and  then  made  to  cut  its  way  outwards,  forming  a  broad, 
rounded  flap.     (Fig.  191.)    The  tissues  on  the  inner  side  of  the  limb  are  next 


Fig.  191 


Amputation  of  leg  by  external  flap,  or  Sedillot's  method. 

divided  by  an  incision  somewhat  convex  anteriorly,  and  the  bones  then  cleared 
by  a  circular  sweep  of  the  knife.  The  interosseous  membrane  being  divided, 
all  the  tissues  are  pushed  upwards  with  the  hand  or  the  handle  of  the  knife, 
so  as  to  expose  the  bone  about  an  inch  higher  up  before  the  application  of 
the  saw. 

It  is  usually  recommended  that,  in  sawing  the  bones  in  any  leg  amputation, 
the  instrument  should  be  held  vertically,  and  both  bones  cut  through  on  the 
same  level;  but  I  am  disposed  to  prefer  the  plan  advised  by  Roux  and  Mal- 
gaigne,  to  wit,  a  separate  division  of  the  bones,  and  the  removal  of  half  an 
inch  more  from  the  fibula  than  from  the  tibia.  Mr.  Syme  and  other  writers 
have  directed  that  the  sharp,  anterior  edge  of  the  tibia  should  be  removed  by 
an  oblique  section  either  with  saw  or  cutting  pliers,  to  prevent  its  perforating 
the  skin  on  the  anterior  face  of  the  stump;  but  this  precaution  is  hardly 
necessary  if  the  flaps  be  sufficiently  ample  to  prevent  undue  tension,  while 
the  oblique  section  of  the  bone  rather  increases,  I  think,  the  risk  of  necrosis 
and  subsequent  exfoliation.  A  better  suggestion,  in  my  judgment,  is  that  of 
Oilier,  of  Lyons,  who  preserves  a  short  flap  of  periosteum  which  is  allowed 
to  fall  over  the  sawn  end  of  the  bone. 

Besides  the  anterior  and  posterior  tibial  and  peroneal  arteries,  there  are 
usually  two  or  three  muscular  and  cutaneous  branches  which  require  ligation, 
and,  in  cases  of  secondary  amputation,  sometimes  a  great  many  more.  Diffi- 
culty is  sometimes  met  with  in  securing  the  anterior  tibial  artery,  on  ac- 
count of  its  retracting  above  the  point  at  which  the  interosseous  membrane 
has  been  divided;  under  these  circumstances  the  patient  mav  be  simply 
turned  over  on  his  face,  when  the  weight  of  the  stump  will  bring  the  knee 
into  an  extended  position,  thus  straightening  the  vessel  and  making  it  more 
accessible.  In  applying  the  tourniquet  for  a  leg  amputation,  the  pad  should 
be  placed  on  either  the  femoral  or  the  popliteal  artery;  if  on  the  latter,  a  some- 


662 


AMPUTATIONS. 


what  broad  compress  should  be  used,  and  the  screw  of  the  instrument  should 
be  applied  diametrically  opposite,  upon  the  front  of  the  limb,  just  above  the 


Lee's  Method. — This  operation,  which  may  be  considered  a  modification 
of  Teale's  method,  was  described  by  Air.  Henry  Lee,  of  St.  George's  Hospital, 
London,  in  a  paper  read  before  the  Royal  Medical  and  Chirurgical  Society  of 
that  city  in  1865. y  The  dimensions  and  shape  of  the  flaps  are  the  same  as  in 
Teale's  method,  but  the  longer  is  taken  from  the  back  of  the  leg,  and  embraces 
only  the  superficial  muscles,  the  deeper  muscles  with  the  vessels  being  divided 
transversely  by  a  circular  incision  on  a  level  with  the  upper  end  of  the  flaps. 
The  long  flap  made  in  this  operation  has  less  bulk  and  weight  than  that  made 
by  the  ordinary  transfixion  method,  but  still  seems  to  me,  unless  in  very 
slender  limbs,  heavier  than  is  desirable.  I  have,  therefore,  in  muscular  sub- 
jects, adopted  a  further  modification,  which  consists  in  separating  the  gastro- 
cnemius from  the  soleus  muscle,  and  including  the  former  only  in  the  flap,  the 
latter  being  divided  circularly  with  the  deeper  layer.     (Fig.  192.) 


Fig.  192. 


Amputation  of  leg  by  Lee's  method  (modified). 

Amputation  above  the  Point  or  Election  may  be  done  by  the  circular,  or 
Larrey's  method,  the  fibula  being  separated  by  disarticulation,  and  the  tibia 
sawn  through  immediately  below  the  attachment  of  the  ligamentum  patellae. 

The  risks  of  amputation  of  the  leg  are  not  inconsiderable,  the  death-rate, 
for  all  cases  taken  together,  being,  as  shown  by  the  Table  on  page  630,  no  less 
than  34.3  per  cent.,  or  more  than  one  in  three.  The  danger  increases 
with  the  proximity  of  the  seat  of  operation  to  the  trunk,  the  mortality 
of  the  supra-malleolar  amputation  being  less  than  that  of  amputation 
at  the  point  of  election.  At  least,  this  has  been  my  own  impression,  and 
it  is  confirmed  by  the  statistics  published  by  Dr.  Gorman  from  the  records  of 
the  Boston  City  Hospital,2  which  give  the  death-rates  of  amputations  in  the 
upper,  middle,  and  lower  thirds  of  the  leg,  as  being  respectively  42.8  per 
cent,  ^>.(.)  p<t  cent.,  and  '22.2  per  cent.  The  late  Dr.  Otis,3  too,  reported  of 
the  supra-malleolar  operation,  that  during  the  late  American  war  its  inor- 


1  Medico-Chirurgical  Transactions,  vol.  xlviii.  p.  195. 

«  Medical  and  Surgical  Reports  of  the  Boston  City  Hospital,  Second  series. 

3  Circular  No.  vi.,  B.  G.  0.,  1865,  p.  47. 


Boston,  1877. 


AMPUTATIONS   AT    THE   KNEE   AND   KNEE-JOINT.  663 

tality-rate  was  "surprisingly  small."  A  different  view  has,  however,  been 
taken  by  other  writers:  thus  Larger1  gives  the  figures  of  the  supra-malleolar 
operation  as  122  cases  with  59  deaths,  a  mortality  of  no  less  than  48.3  per 
cent.,  while  Legouest2  reports  that  in  the  French  army,  in  the  Crimean  war, 
47  eases  gave  26  deaths,  a  mortality  of  55.4  per  cent.,  or  somewhat  larger 
than  that  of  all  leg  amputations  taken  together. 


Amputations  at  the  Knee  and  Knee-joint. 

By  amputation  at  the  knee-joint  is  meant  a  pure  disarticulation  ;  in  amputa- 
tion at  the  knee,  a  larger  or  smaller  portion  of  the  femoral  condyles  is  also 
removed,  and  in  this  category  are  included  the  various  special  forms  of  ope- 
ration which  are  known  as  Garden's  and  Gritti's,  and  the  "supra-condvloid 
amputation"  of  Dr.  Stokes. 

Amputation  at  the  Knee-joint. — This  operation,  though  briefly  referred 
to  by  the  older  writers,  and  resorted  to  in  isolated  instances  by  Petit,  Iloin, 
Brasdor,  Rieherand,  Nathan  Smith,  of  Xew  Haven,  and  other  surgeons,  has 
only  been  accepted  as  a  recognized  mode  of  procedure  for  a  little  over  fifty 
years,  having  been  advocated  and  introduced  into  modern  practice  by  Velpeau, 
whose  first  operation  appears  to  have  been  performed  in  January,  1830.  ]  dis- 
articulation at  the  knee-joint  may  be  done  by  either  the  circular  or  the  ellip- 
tical method,  or  by  making  anterior,  posterior,  or  lateral  flaps.  The  circular 
method  presents  no  special  advantage  in  this  locality,  and  it  is  difficult  of  per- 
formance on  account  of  the  irregular  shape  of  the  part.  The  best  operations 
in  this  situation  are,  I  think,  the  elliptical  and  the  anterior  flap  methods. 

Elliptical  Method. — In  this  operation,  which  is  known  as  Baudens's,  the 
surgeon  begins  his  incision  over  the  posterior  part  of  the  inner  tuberosity  of 
the  tibia,  about  an  inch  and  a  half  below  the  line  of  the  articulation  ;  cutting 
at  first  longitudinally  downwards,  the  knife  is  then  made  to  cross  the  front 
of  the  limb  with  a  curved  incision,  concave  upwards,  and  reaching  two  and  a 
half  or  three  inches  below  the  tibial  tubercle,  thence  passing  upwards  on  the 
outer  side  to  a  point  half  an  inch  below  and  behind  the  head  of  the  fibula, 
and  finally  across  the  back  of  the  limb  in  a  slightly  curved  incision,  convex 
upwards,  to  the  place  of  commencement.  In  the  last  part  of  the  incision, 
the  superficial  muscles  should  be  divided  as  well  as  the  skin.  The  large 
anterior  flap  thus  marked  out  is  now  dissected  upwards,  keeping  the  edge 
of  the  knife  close  to  the  bone,  until  the  ligamentum  patella  is  exposed ;  this 
is  next  divided  transversely,  and  disarticulation  then  effected  by  cutting  the 
lateral  and  crucial  ligaments — the  knee  being  forcibly  flexed  for  the  purpose — 
when  finally  the  knife  is  slipped  behind  the  joint,  and  the  tissues  of  the  ham 
cut  through  from  within  outwards  by  a  single  stroke.  The  popliteal  is  the 
only  large  artery  divided,  though  several  small  branches  usually  require  liga- 
tion also.  The^ wound  is  brought  together  from  before  backwards,  so  as'to 
furnish  a  semicircular  cicatrix  which  shall  be  well  protected  behind  the  con- 
dyles of  the  femur. 

Anatomically,  this  operation  should  afford  a  better  stump  than  any  other 
method,  but  it  is  almost  invariably  found  in  practice  that  the  retraction  at 
the  back  of  the  wound  is  so  great  as  to  render  its  closure  very  difficult,  and  to 
cause  so  much  tension  upon  the  sutures  as  to  endanger  the  vitality  of  the 
tissues.     The  anterior  flap  method  preserves  all  its  good  features,  and,  by 

1  Bulletin  de  la  SoeiSte"  de  Chirurgie,  apud  Revue  des  Sciences  MeYlieales,  Oct.  15,  18S0. 
8  Traite  de  Chirurgie  d'Armee,  p.  734.     Paris,  18G3. 


664 


AMPUTATIONS. 


superadding  a  square  flap  from   the  back  of  the   limb,  obviates  its  dis- 
advantages. 

Posterior  Flap  Method. — This,  which  is  known  as  Horn's  method,  I  do  not 
hesitate  to  pronounce  to  be  a  bad  operation.  The  large  muscular  flap,  taken 
from  the  calf,  is  so  heavy  as  to  be  with  difficulty  kept  in  position,  and  the 
resulting  cicatrix  is  placed  in  the  least  desirable  position. 

Anterior  Flap  Method. — This,  which  is  essentially  the  method  adopted  by 
Nathan  Smith,  of  ISTew  Haven,  in  1824,  is,  I  think,  upon  the  whole,  the  best 
mode  of  removing  the  limb  at  the  knee-joint.  The  anterior  flap,  which  is 
almost  entirely  a  cutaneous  one,  is  made  very  much  as  the  anterior  branch  of 
the  ellipse  in  Baudens's  operation,  except  that  it  is  rather  more  square  (Fig. 
193);  a  shorter,  square,  posterior  flap  is  also  cut  from  the  integument  of  the 

Fig.  193. 


Amputation  at  knee-joint  by  anterior  flap  method. 

upper  part  of  the  calf,  and,  after  disarticulation,  the  wound   is  brought 
together,  making  a  small  cicatrix  which  is  well  protected  from  pressure. 

Lateral  Flap  Method. — This  mode  of  performing  the  operation  was  intro- 
duced by  Rossi,  and  consists,  as  its  name  implies,  in  taking  flaps  from  either 
side  of  the  leg,  the  resulting  cicatrix  being  placed  midway  between  the  two 
femoral  condyles.  This  operation  has  been  improved  by  Prof.  Stephen  Smith, 
of  \e\v  York,  by  carrying  the  point  at  which  the  flaps  join  posteriorly  further 
up  than  in  front.  A  convenient  means  of  effecting  drainage  is  thus  provided, 
while  the  natural  coverings  of  the  front  of  the  knee  are  not  interfered  with. 
A  similar  operation  is  employed  by  Prof.  Smith  in  amputating  both  above 
and  below  the  knee. 

Some  difference  of  opinion  exists  as  to  whether  or  no  the  patella  should  be 
removed  in  amputating  at  the  knee-joint,  but  I  strongly  recommend  that  it 
should  be  retained.  Its  presence  adds  greatly  to  the  rotundity  and  firmness 
«>f  the  stump,  and  its  removal  renders  the  anterior  flap  so  thin  that  sloughing 


AMPUTATIONS   AT    THE   KNEE   AND   KNEE-JOINT. 


665 


Fig.  194. 


may  follow.  Mr.  Eriehscn  advises  that,  in  order  to  prevent  retraction,  the 
flap  should  be  turned  upward  and  the  attachment  of  the  quadriceps  femoris 
divided,  but  in  my  own  cases  I  have  not  found  this  necessary.  The  semi- 
lunar cartilages  should,  I  think,  be  removed,  though  A.  Guerin  recommends 
their  retention.  The  articular  cartilage  of  the  femur  need  not  be  interfered 
with:  it  undergoes  spontaneous  separation,  by  a  process  of  slow  exfoliation, 
and  comes  away  with  the  discharge  in  shreds  or  fragments  of  greater  or  less 
size  during  the  second  or  third  week ;  some  writers  advise  that  it  should  be 
removed  by  sawing  around  the  condyles  with  a  Butcher's  saw,  but  this  seems 
to  me  an  unnecessary  complication. 

Amputation  at  the  Knee. — Amputation  at  the  knee,  as  distinguished  from 
the  knee-joint,  may  be  done  by  any  of  the  methods  above  described,  the  only 
difference  between  this  operation  and  the 
disarticulation  being  that  a  portion  more  or 
less  considerable  of  the  end  of  the  femur  is 
removed  by  sawing  through  the  condyles. 
The  anterior  flap  method  gives,  I  think,  the 
best  result,  and,  the  patella  being  retained, 
furnishes  an  admirably  firm  and  rounded 
stump.  Several  special  forms  of  operation 
are  practised  in  this  situation,  and  may  be 
here  briefly  referred  to. 

Garden's  Amputation. —  This  operation, 
which  was  introduced  by  Mr.  Carclen,  of 
Worcester,  is  done  by  taking  a  large  rounded 
skin  flap  from  the  front  of  the  knee;  divid- 
ing the  tissues  on  the  back  of  the  limb  by  a 
single  transverse  incision,  made  either  by 
transfixion  or  from  without  inwards,  on  a 
level  with  the  base  of  the  flap ;  reflecting  the 
flap  and  dividing  the  deeper  tissues  straight 
down  to  the  bone,  above  the  patella  which 
is  drawn  downwards  by  flexing  the  knee; 
and  finally  sawing  through  the  base  of  the 
condyles.  (Fig.  194.)  This  method  of  ope- 
rating is  undoubtedly  better  than  Syme's 
plan  (which  that  surgeon  abandoned  in  favor 
of  Carden's)  of  taking  a  posterior  flap  to 
cover  the  sawn  end  of  the  condyles,  but 
seems  to  me  less  desirable  than  that  which  I 
have  described  simply  as  amputation  at  the 
knee — a  posterior  being  added  to  the  anterior  flap,  and  the  patella  being  pre- 
served. It  has,  however,  been  very  successful  in  the  hands  of  its  author, 
thirty  cases  recorded  b}^  Mr.  Carden  himself  having  given  but  five  deaths 
and  twenty-five  recoveries.1 

GinttVs  Amputation. — This  operation,  introduced  by  Rocco  Gritti,  of  Milan, 
in  1857,2  may  be  regarded  as  an  application  of  the  osteo-plastic  method  of 
Pirogoft',  to  amputations  at  the  knee.  A  rectangular  flap  is  taken  from  the 
front  of  the  leg  and  knee,  and  a  shorter  flap  from  the  back  of  the  limb ;  the 

1  British  Medical  Journal,  1864.     Mr.  Carden  reports  thirty-one  cases,  one  of  which,  however, 
appears  to  have  been  a  disarticulation. 

2  Annali  Universali  di  Medicina.     Milano,  1857. 


Amputation  at  knee  by  Carden's  method. 


666 


AMPUTATIONS. 


lower  surface  of  the  patella  is  removed  with  a  small  saw,1  and  the  condyles 
similarly  divided  through  their  base,  the  two  sawn  surfaces  being  then  brought 
into  apposition.  A  very  good  stump  results  from  this  rather  complicated 
procedure. 

Stokes's  Modification  of  Gritti's  Amputation  is  called  by  its  author,  Dr.  W. 
Stokes,2  of  Dublin,  a  supra-cut ulyloid  amputation  of  the  thigh,  whereas  the  line 
cf  section  in  Gritti's  method  is  trans-condyloid.  This  operation  differs  from 
that  of  the  Italian  surgeon  simply  in  the  fact  that  the  anterior  flap  is  oval 
instead  of  being  rectangular;  that  the  posterior  flap  is  made  somewhat  larger 
(one  third  the  length  of  the  anterior) ;  and  that  the  femur  is  sawn  through  half 
an  inch  above  the  condyles,  instead  of  through  their  base.  The  freshly  sawn 
surfaces  of  the  femur  and  patella  are  brought  together  as  in  the  Italian  opera- 
tion, and  fixed  by  means  of  a  catgut  suture  passed  through  the  soft  tissues 
immediately  behind  the  bone,  and  with  both  ends  cut  short  and  left  in  the 
wound. 


The  merits  of  these  various  forms  of  operation  have  been  investigated  by 
numerous  surgeons,  among  whom  I  may  particularly  mention  Profs.  Stephen 
Smith3  and  Markoe,4  and  Dr.  R.  F.  Weir,5  of  K"ew  York  ;  Dr.  J.  H.  Brinton,6 
of  Philadelphia ;  Mr.  Pollock,7  of  London ;  and  Dr.  Salzmann,8  of  Potsdam, 
who  has  particularly  studied  Gritti's  method  in  regard  to  its  applicability  in 
military  practice.  Dr.  Brinton,  including  in  his  Tables  Prof.  Markoe's  and 
Dr.  Otis's  cases,  refers  in  all  to  494  examples  of  these  different  operations, 
death  having  followed  in  207  ;  Dr.  Weir  tabulates  76  cases  (of  Gritti's  and 
Stokes's  operations)  with  22  deaths ;  Mr.  Pollock  48  cases  of  various  kinds 
with  13  deaths  ;  while  Dr.  Salzmann  collects,  in  all,  396  cases  with  231  deaths. 
In  the  following  Table  I  have  included  only  terminated  cases,  and  have  taken 
care  to  avoid  duplication  in  combining  the  statistics  of  the  various  authors 
quoted. 

Table  showing  the  Results  of  Amputations  at  the  Knee  and  Knee-joint. 


Authority. 

Cases. 

Deaths. 

Mortality 
per  cent. 

Reference. 

Brinton  (various  sources) 

233 

76 

32.6 

Amer.  Journ.  of  the  Med.  Sciences, 
April,  1868. 

Otis  (American  war) 

202 

106 

52.4 

Ibid.     (Quoted  by  Brinton.) 

Garden  (knee-amputation)     . 

30 

5 

16.6 

British  Med.  Journal,  April  16, 
1864. 

Bryant  (individual  experience) 

23 

5 

21.7 

Manual  for  the  Practice  of  Surgery, 
Third  edition. 

Pollock  (various  sources) 

42 

13 

30.9 

Med.-Chir.  Transactions,  vol.  liii. 

Legouest  (Crimean  war) 

85 

75 

88.2 

Traite  de  Chirurgie  d'Armee,  18(i3. 

Salzmann,  knee-amputations  (va- 

138 

67 

48.5 

Archiv    fur    klin.    Chirurgie,    Bd. 

rious  sources) 

xxv.  H.  3. 

Id.,  knee-joint  amputations  (Mexi- 

can,    Italian,    Austrian,    and 

Franco-German  wars) 

41 

32 

7S.+ 

Ibid. 

Aggregates 

794 

379 

47.7 

1  Mr.  Pollock  employs  cutting  forceps  for  this  purpose; 

'■'■  Medioo-Chirurgical  Transactions,  vol.  liii.  p.  175.     London,  H 

3  New  York  Journal  of  Medicine,  November,  1852. 

4  New  York  Medical  Journal,  March,  1868. 

s  New  York  Medical  Record,  April  12,  1879. 

8   American  Journal  of  tbe  Medical  Sciences,  April,  1868. 

i  Medico-Chirurgioal  Transactions,  vol.  liii.  1870. 

8  Archiv  fur  klinische  Chirurgie,  Bd.  xxv.  H.  3,  1880. 


AMPUTATION   OF   THE    THIGH.  667 

The  general  death-rate,  then,  of  these  amputations  at  the  knee-joint  and 
knee,  appears  to  be  47.7  per  cent.,  or  not  quite  one  in  two.  Comparing  this 
with  the  mortality  of  leg  and  with  that  of  thigh  amputations,  as  given  in 
the  Table  on  page  630,  we  find  it  almost  midway  between  them,  thus  sustain- 
ing the  general  rule  that  the  gravity  of  amputation  increases  as  the  opera- 
tion is  done  nearer  the  trunk.  , 

Cases.  Deaths.  Mortality  per  cent. 

Amputation  of  the  leg 5247  1804  34.3 

"  "         knee 794  379  47.7 

"  "         thigh 5606  3527  63.8 

It  is  difficult  to  estimate  the  comparative  mortality  of  the  special  forms  of 
amputation  which  have  been  referred  to,  as  authors  do  not  distinguish  clearly 
between  them ;  thus  Dr.  Brinton  includes  cases  of  Gritti's  operation  with 
ordinary  amputations  at  the  knee;  Dr.  Otis  groups  together  all  amputations 
whether  of  the  knee  or  knee-joint ;  and  Dr.  iSalzmann  embraces  in  his  Table 
of  Gritti's  operations,  many  cases  in  which  the  condyles  were  not  touched. 
As  a  practical  rule  for  treatment,  I  would  advise  that  when  there  is  ample 
tissue  for  the  formation  of  flaps,  and  the  joint  itself  is  not  involved,  simple 
disarticulation  should  be  preferred ;  but  that  under  other  circumstances  the 
condyles  should  be  removed.  The  patella  is,  I  think,  best  retained  under  all 
circumstances;  if  it  is  itself  diseased, however,  its  articulating  surface  should 
be  excised  either  with  saw  or  cutting  forceps. 


Amputation  of  the  Thigh. 

The  thio;h  may  be  amputated  by  almost  any  of  the  methods  which  are 
employed  in  other  parts  of  the  body,  but  those  which  I  am  in  the  habit  of 
employing,  and  to  which  I  give  the  preference,  are  the  anteroposterior  flap 
operation,  for  amputations  in  the  lower  third  of  the  thigh,  and  for  those  in 
the  middle  and  upper  thirds,  the  modified  circular. 

Amputation  in  the  Lower  Third  of  the  Thigh. — This  operation  is  often 
required  in  cases  of  injury  involving  the  knee-joint,  such  as  compound  frac- 
tures and  dislocations,  and  in  cases  of  disease  of  that  articulation,  in  which 
the  femur  is  too  extensively  implicated  to  permit  of  amputation  through  the 
condyles.  The  double  flap  method  is  the  best  in  this  situation,  and  I  much 
prefer  to  take  the  flaps  from  the  front  and  back  of  the  thigh  (Fig.  195), 
rather  than  from  its  sides,  because  the  femur  being  placed  very  near  the  front 
of  the  limb,  its  sawn  end  is  apt  to  protrude  through  the  wound  when  the 
operation  by  lateral  flaps  is  adopted.  In  amputating  by  anteroposterior  flaps, 
the  surgeon  introduces  his  knife  on  the  side  of  the  "thigh,  an  inch  or  an  inch 
and  a  half  below  the  point  at  which  he  intends  to  divide  the  bone,  and  car- 
ries the  blade  longitudinally  downwards  for  a  space  fully  equal  to  half  the 
diameter  of  the  part,  then  crossing  in  front  of  the  limb  with  a  curved  incision, 
convex  downwards,  and  finally  ascending  to  a  point  on  the  other  side  of  the 
limb,  opposite  to  that  at  which  the  incision  was  begun.  There  is  thus  marked 
out  a  rather  square  flap,  with  rounded  corners,  reaching  usually  to  the  upper 
borderof  the  patella.  This  flap  is  dissected  up  with  rapid  strokes  of  the 
knife,  including  all  the  tissues  down  to  the  bone,  and  is  then  intrusted  to  an 
assistant,  while  the  operator  forms  the  posterior  flap  by  transfixing  the  limb 
behind  the  femur,  and  cutting  first  downwards,  with  a  sawing  motion,  and 
then  almost  directly  backwards.  The  posterior  flap  should  be  made  nearly  as 
long  as  the  anterior,  the  greater  retraction  of  the  muscles  at  the  back  of  the 


668 


AMPUTATIONS. 


thigh  rendering  it  important  that  the  lower  flap  should  he  of  ample  size.  If 
the  knife  be  kept  close  to  the  bone,  in  cutting  the  posterior  flap,  this,  if  the 
limb  be  a  large  one,  will  be  found  to  be  thick  and  unwieldy  ;  hence  in  ope- 
rating upon  muscular  subjects,  it  is  better  to  follow  Sedillot's  plan,  and,  by 
keeping  the  knife  away  from  the  bone,  include  in  the  flap  only  the  superficial 

Fig.  195. 


Amputation  of  thigh  by  antero-posterior  flap  method. 

muscles ;  or  the  flap  may  be  made  of  the  proper  dimensions  by  cutting  it 
from  without  inwards.  Both  flaps  having  been  formed,  the  bone  is  cleared 
by  a  circular  sweep  of  the  knife,  and  the  tissues  are  then  pushed  upwards,  so 
as  to  allow  the  application  of  the  saw  an  inch  or  more  above  the  point  of 
junction.  At  least  seven  or  eight  ligatures  will  be  required  after  amputation 
in  the  lower  third  of  the  thigh,  and  sometimes  a  much  larger  number.  An 
admirable  stump  is  afforded  by  this  mode  of  operating,  the  bone  being  well 
covered  by  the  anterior  flap,  and  the  cicatrix  drawn  out  of  the  line  of  pres- 
sure. In  applying  the  tourniquet  for  amputations  in  the  lower  part  of  the 
thigh,  the  compress  should  be  placed  over  the  femoral  artery  at  the  apex  of 
Scarpa's  triangle. 

Amputation  in  the  Middle  or  Upper  Third  of  the  Thigh. — In  either  of 
these  situations,  the  best  operation  is,  I  think,  the  modified  circular.  The  skin 
flaps  should  be  taken  from  the  front  and  back  of  the  limb  (see  Fig.  147,  page 
588),  and  care  should  be  taken,  after  dividing  the  muscles,  to  push  them  well 
upwards,  so  that  the  bone  may  be  sawn  at  a  considerably  higher  point.  The 
muscles  on  the  back  of  the  limb  should  be  cut  rather  longer  than  those  in 
front,  on  account  of  their  greater  tendency  to  retraction.  In  amputating  at 
the  upper  part  of  the  thigh,  there  may  not  be  room  for  the  application  of  the 
tourniquet,  and  the  surgeon  must  then  use  an  aortic  compressor  of  some  kind 
(as  in  amputating  at  Hie  hip),  or  must  rely  upon  manual  pressure  by  an  assist- 
ant. The  best  mode  of  controlling  the  circulation  by  manual  compression,  is, 
standing  beside  and  behind  the  patient,  to  grasp  the  great  trochanter  of  the 
limb  to  be  removed  with  the  fingers  of  the  corresponding  hand,  and  with  the 
thumb  make  firm  pressure  on  the  artery  just  below  Poupart's  ligament;  the 


AMPUTATION   AT    THE   HIP-JOIXT.  669 

thumb  of  the  other  hand  is  at  the  same  time  superimposed  to  regulate  aud  aid 
the  compression,  and  to  prevent  any  danger  of  slipping. 

Amputation  through  the  Trochanters. — This  operation,  which  is  only 
less  grave  than  amputation  at  the  hip-joint,  may  be  required  in  cases  of  injury, 
or  in  those  of  tumor  involving  the  lower  part  of  the  femur.  When  practi- 
cable, it  should  be  preferred  to  disarticulation,  even  in  cases  of  malignant 
growth,  as  being  a  less  dangerous  operation  in  itself,  and  as  no  more  likely 
to  be  followed  by  recurrence  of  the  disease,  which,  when  it  does  return,  is  at 
least  as  apt  to  attack  the  pelvis  as  the  stump  itself.  Should  it  be  found, 
moreover,  after  sawing  through  the  trochanters,  that  the  disease  has  extended 
higher  up,  it  is  very  easy  to  convert  the  operation  into  a  disarticulation  by 
simply  dissecting  out  the  head  and  neck  of  the  femur.  The  modified  circular 
operation  is  well  adapted  for  amputations  in  this  situation. 

The  above  are  the  modes  of  operating  to  which  I  would  advise  a  resort  in 
cases  of  thigh  amputation,  in  which  the  surgeon  has  the  opportunity  of 
selecting  his  method.  It  may  well  happen,  however,  that  the  structures  on 
one  side  of  the  limb  may  be  hopelessly  diseased  or  injured,  while  those  on 
the  opposite  side  may  be  comparatively  healthy ;  under  such  circumstances 
the  surgeon  must  try  to  utilize  the  sound  parts  wherever  they  are  situated,  and 
must  secure  a  covering  for  the  stump  from  whatever  part  is  most  available  for 
the  purpose.  Single  flaps,  double  flaps,  triple  flaps — any  device  may  be  resorted 
to — it  being  much  more  important  in  any  given  case  to  remove  the  limb  at 
as  low  a  point  as  possible,  than  to  follow  the  details  of  any  particular  plan 
of  procedure.  Teales  method  affords  a  beautiful  and  useful  stump  in  thigh 
amputations,  but,  for  reasons  already  given  (page  588),  it  seems  to  me  an  un- 
desirable operation  in  this  particular  locality. 

The  death-rate  of  thigh  amputations,  taken  all  together,  appears  from  the 
Table  on  page  630  to  be  63.8  per  cent.,  or  more  than  Ave  in  eight.  From  the 
figures  on  the  same  page,  it  is  seen  that,  in  military  practice,  the  mortality  has 
varied  from  about  one  in  two,  for  amputations  in  the  lower  third  of  the  thigh, 
to  the  enormous  proportion  of  seven  in  eight,  for  amputations  in  the  upper 
part  of  the  limb. 


Amputation  at  the  Hip-joint. 

The  removal  of  the  lower  limb  at  the  coxo-femoral  articulation  may  be 
properly  regarded  as  the  gravest  operation  which  the  surgeon  is  ever  called 
upon  to  perform,1  and  it  is  only  within  a  comparatively  recent  period  that  it 
has  beeu  accepted  as  a  justifiable  procedure.  Ravaton  wished  to  perform  tlie 
operation  in  1743,  but  the  other  surgeons  called  in  consultation  forbade  the 
attempt.2  The  case  usually  referred  to  as  the  first  amputation  at  the  hip,  oc- 
curred five  years  later  (1748),3  in  the  person  of  a  lad  of  13  or  14,  who  had 
been  attacked  with  gangrene  of  both  lower  extremities  as  the  result  of  eating 
spurred  or  smutty  rye  (ble  ergote).  On  the  right  side  a  line  of  separation 
had  formed  at  the  hip,  and  when  the  limb  was  almost  completely  detached 

1  "  Obliged,  as  we  are,"  says  Hennen  (Principles  of  Military  Surgery,  page  40.  Third  edition. 
London,  1829),  "  coolly  to  form  our  calculations  in  human  blood,  there  is  still  something  in  the 
idea  of  removing  the  quarter  of  a  man,  at  which  the  boldest  mind  naturally  recoils."  "  Thes- 
is not  one  patient  in  a  thousand  that  would  not  prefer  instant  death  to  the  attempt." 

2  Velpeau,  op.  cit.,  t.  ii.  p.  538. 

s  Barbet,  Prix  de  l'Academie  Royale  de  Chirurgie,  t.  iv.  p.  47.     Paris,  1819. 


670  AMPUTATIONS. 

by  the  efforts  of  nature,  M.  Lacroix,  the  attending  surgeon,  removed  it  by 
simply  dividing  with,  scissors  the  ligamentum  teres  and  the  sciatic  nerve. 
Four  days  afterwards,  the  left  limb  was  painlessly  and  bloodlessly  amputated 
on  a  level  with  the  great  trochanter,  by  sawing  through  the  bone  which  was 
exposed  by  the  separation  of  the  gangrenous  soft  parts.  The  patient  did  well 
for  a  while,  but  finally  succumbed,  eleven  days  after  the  second,  and  fifteen 
days  after  the  first  operation.  A  quarter  of  a  century  later  (1773  or  1774), 
Perault,  a  surgeon  of  Sainte-Maure,  performed  a  similar  operation  upon  a 
man  named  Francois  Gois,  whose  thigh  had  been  crushed  between  the  pole 
of  a  carriage  and  a  wall,  and  had  subsequently  become  gangrenous.  The 
limb  was  almost  entirely  separated  by  the  processes  of  nature,  and  Perault 
merely  completed  its  removal.  The  patient  recovered,  and  twenty  years 
afterwards  was  working  as  a  cook  in  an  inn  of  Sainte-Maure,  was  married, 
and  had  a  healthy  child.1 

The  first  amputation  at  the  hip,  through  living  parts,  appears  to  have  been 
performed  by  Mr.  Henry  Thomson,  Surgeon  to  the  London  Hospital,  some 
time  before  1777 — that  is,  if  his  namesake,  Dr.  John  Thomson,2  is  correct  in 
supposing  that  it  was  this  case  the  "  horridness"  of  which  provoked  Mr.  Per- 
cival  Pott's  denunciation  of  the  procedure,  in  his  Remarks  on  Amputation, 
written  in  that  year.3  In  December,  1778,  Mr.  Kerr,  of  JSTorthampton,  ampu- 
tated at  the  hip  in  the  case  of  a  girl  of  eleven  years,  who  was  suffering  from 
advanced  hip-disease  and  phthisis,  and  who  survived  the  operation  eighteen 
days.4  The  first  hip-joint  amputation  in  military  practice  occurred  in  1793, 
the  patient  being  a  French  soldier  of  the  Army  of  the  Rhine,  and  the  ope- 
rator, the  illustrious  Baron  Larrey.5  The  case  terminated  unfavorably  owing 
to  the  patient's  being  obliged  to  accompany  the  troops  in  a  forced  march, 
which  they  were  compelled  to  undertake  a  few  hours  after  the  operation. 
Three  cases  (two  successful)  are  attributed  to  the  elder  Blandin  (Larrey's  as- 
sistant), in  1794,  but,  though  Velpeau  and  Lisfranc  both  refer  to  them,  they 
give  no  reference  to  their  authority,  and  certain  contemporary  or  nearly  con- 
temporary writers,  including  Larrey  and  the  younger  Blandin,6  do  not  men- 
tion their  occurrence,  so  that  their  authenticity  has  been  called  in  question. 
Brownrigg  (in  1811)  was  the  first  British  army  surgeon  to  attempt  the  opera- 
tion, which  he  repeated  successfully  in  the  following  year,  the  latter  case  being, 
if  Blandin's  claims  are  disregarded,  the  first  instance  of  recovery  from  the 
operation  known  to  military  surgery. 

Amputation  at  the  hip-joint  may  be  performed  in  many  ways — Farabeuf 
speaks  of  over  forty-five  methods — and  writers  on  Operative  Surgery  describe 
more  than  one  mode  of  procedure  recommended  by  surgeons  who,  whatever 
their  skill  in  operating  upon  the  dead  body,  have  never  had  occasion  to 
amputate  at  the  hip  of  a  living  person.  I  shall  enumerate  only  the  more 
important  methods. 

Oval  Method. — On  a  slender  limb,  this  operation,  which  is  known  by  the 
name  of  Cornuau  and  Scoutetten,  gives  ;i  well-formed  and  serviceable  stump, 
]  iarticularly  if  Malgaigne's  modification  (en  rccquette)he  adopted.  The  surgeon 
first  makes  a  longitudinal  incision  of  about  three  inches  on  the  outer  side  of 

1  Sabatier,  quoted  by  Wlpeau,  op.  cit.,  t.  ii.  p.  539,  and  by  Lisfranc,  op.  cit.,  t.  ii.  p.  381. 

2  Report  of  Observations  made  in  the  British  Military  Hospitals  in  Belgium,  etc.,  p.  2(j4.  Edin- 
burgh, 1816. 

3  Chirorgical  Works  of  Peroival  Pott,  vol.  iii.  p.  218,  and  Life,  l>y  Sir  James  Earle,  Ibid.,  vol. 
i.  p.  xxv,      London,  18(is. 

4  Medical  and  Philosophical  Commentaries.  By  a  Society  in  Edinburgh,  vol.  vi.  Part  iii.  page 
337.     London,  1779. 

5  Memoires  de  Chirurgie  Militaire  et  Campagnes,  t.  ii.  p.  180.     Paris,  1812. 

6  Dictionnaire  do  Me"decine  et  do  Chirurgie  Pratiques,  t.  ii.  p.  280.     Paris,  1829. 


AMPUTATION   AT   THE   HIP-JOINT.  671 

the  limb,  over  the  trochanter  major,  and  then  diverges  in  front  and  behind, 
carrying  the  lateral  branches  of  the  oval  obliquely  downwards  and  inwards, 
until  they  meet  transversely  on  the  inner  side  of  the  thigh.  The  first  inci- 
sions divide  the  skin  and  fascia,  and  the  next  step  is  the  severance  of  the 
muscles  (except  in  the  region  of  the  main  vessels),  at  the  same  level  or  a  little 
higher.  The  joint  is  opened  from  the  outer  side,  and,  after  disarticulation, 
the  remaining  tissues  are  cut  through  from  within  outwards  as  in  Larrey's 
similar  operation  at  the  shoulder.  However  appropriate  this  operation  may 
be  in  the  case  of  a  patient  emaciated  by  disease,  it  is  evident  that,  in  a  robust 
limb,  the  adductor  muscles  would  form  a  bulky  and  cumbrous  mass,  which 
would  interfere  with  the  satisfactory  adjustment  of  the  wound,  and  would 
probably  prevent  primary  union. 

Modified  Circular  Method. — This  mode  of  operating  is  particularly  indi- 
cated when  amputation  is  required  on  account  of  a  tumor  which  encroaches 
upon  the  upper  part  of  the  limb.  Short  antero-posterior  skin  flaps  are  cut 
from  without  inwards,  and  the  muscles  then  divided  by  a  circular  incision  at 
the  level  of  the  joint.  This  form  of  operation  is  convenient  when  the  surgeon 
is  not  satisfied  that  the  circulation  is  thoroughly  controlled  by  pressure,  as 
it  exposes  the  femoral  artery  and  vein,  and  affords  an  opportunity  for  securing 
them  with  ligatures  before  they  are  divided.  The  modified  circular  method 
has  been  rather  a  favorite  with  American  surgeons,  in  this  situation,  and  I 
may  particularly  mention,  among  those  who  have  adopted  it,  the  late  Dr.  J. 
Mason  Warren,  of  Boston,  and  my  colleague,  Prof.  Agnew,  of  Philadelphia. 

Single  Flap  Method. — This  operation,  which  seems  to  be  the  favorite 
with  most  French  surgeons,  is  performed  by  taking  a  large  flap  from  the 
anterior  or  antero-internal  surface  of  the  limb,  and  dividing  the  remaining 
tissues  by  a  circular  incision,  either  before  or  after  disarticulating.  The  Hap 
is  usually  made  by  transfixion,  the  operation  then  being  known  by  the  name 
of  Manec.  A  long,  double-edged  knife  is  entered  flatwise,  midway  between 
the  anterior  superior  spinous  process  of  the  ilium  and  the  great  trochanter 
(the  limb  being  slightly  flexed  so  as  to  relax  the  muscles  on  its  anterior  sur- 
face), and  directed  "at  first  inwards  and  a  little  upwards,  so  as  to  graze  the 
head  of  the  femur  and  open  the  capsule  of  the  joint.  The  handle  of  the  knife 
is  then  raised  so  as  to  depress  its  point,  and  transfixion  is  next  effected  by 
pushing  the  instrument  steadily  onwards  until  it  emerges  at  the  middle  of 
the  line  which  separates  the  thigh  from  the  scrotum.  The  flap  is  then  formed 
by  cutting  downwards  with  a  sawing  movement,  keeping  the  knife  close  to 
the  bone,  and  taking  care  to  make  the  inner  part  of  the  flap  as  long  as  the 
outer:  the  flap  is  terminated  at  the  middle  of  the  thigh.  An  assistant  slips 
his  fingers  beneath  the  flap,  and  grasps  the  femoral  artery  before  it  is  divided. 
The  surgeon  then  opens  the  joint  from  the  front,  cuts  the  muscles  on  either 
side,  the  ligainentum  teres,  and  the  muscles  attached  to  the  great  trochanter, 
and  finally  completes  the  separation  of  the  limb  by  making  a  transverse  inci- 
sion through  the  posterior  tissues,  from  without  inwards.  Lenoir  modified 
Manec's  procedure  by  dividing  the  tissues  on  the  back  of  the  limb  before  dis- 
articulating. 

Other  modes  of  performing  the  single  flap  operation  are  that  of  Lalouette, 
who  began  with  a  transverse,  external  incision,  then  disarticulated,  and  cut 
an  internal  flap  as  the  last  stage  of  his  procedure;  that  of  Plantade  and  Ash- 
mead  (of  Philadelphia),  who  made  an  anterior  flap  by  cutting  from  without 
inwards ;  and  that  of  JDelpech,  who  first  tied  the  femoral  artery  below  Pou- 
part's  ligament,  then  cut  an  internal  flap  by  transfixion,  and  finally  severed 
the  external  tissues,  thus  reversing  the  steps  of  Lalouette's  method. 


G72 


AMPUTATIONS. 


The  single  flap  operation  may  be  suitably  resorted  to  when  the  destruction 
of  the  soft  parts,  by  injury  or  disease,  has  extended  much  further  on  one  side 
of  the  limb  than  on  the  other ;  and  it  may  even  be  proper,  under  such  cir- 
cumstances, to  employ  a  posterior  flap ;  but  when  the  surgeon  can  choose  his 
operation,  he  will,  I  think,  do  better  to  adopt  either  the  oval  or  modified  cir- 
cular, or  the  double-flap  method  after  the  manner  of  Guthrie,  which  will  be 
presently  referred  to. 

Antero-posterior  Flap  Method. — We  may  recognize  three  varieties  of  this 
operation,  which  I  shall  designate  respectively  by  the  names  of  Liston,  Bee- 
lard,  and  Guthrie. 

Liston's  Method. — This  form  of  the  operation  is  very  generally  adopted  in 
England  and  in  this  country,  and  is,  perhaps,  the  best  of  the  transfixion 
methods.  The  point  of  a  long  knife  is  introduced  between  the  great  tro- 
chanter and  the  anterior  superior  spinous  process  of  the  ilium ;  made  to 
graze  the  anterior  surface  of  the  neck  of  the  femur ;  and,  finally,  brought  out 
just  in  front  of  the  tuber  ischii,  \ery  much  as  in  Manec's  procedure.  An 
antero-internal  flap,  about  five  inches  in  length,  is  then  cut  from  within  out- 
wards, and,  after  disarticulation,  a  corresponding  flap  is  cut  from  the  buttock 
and  tissues  on  the  back  of  the  thigh. 


Beclard's  Method. — In  this  procedure  the  posterior  flap  is  cut  first.  The 
point  of  the  knife  is  introduced  a  little  above  the  trochanter ;  pushed  across 
the  limb,  grazing  the  back  of  the  femoral  neck ;  and  made  to  emerge  at  the 
innermost  part  of  the  gluteal  crease.     A  flap  is  then  cut  from  the  tissues  of 


Fie.  196. 


Amputation  at  hip-joint  by  B6clard's  method. 

the  buttock,  and  the  knife,  being  re-introduced  at  the  same  point  as  before, 
is  made  to  traverse  the  limb,  this  time  in  front  of  the  joint,  and  to  cut  the 
anterior  i!;ip  from  the  front  of  the  thigh.  Disarticulation  is  in  this  method 
the  last  step  of  the  operation.    (Fig.  196.) 

Guthrie's  Method.-  This  is,  T  think,  upon  the  whole,  the  best  mode  of  am- 
putating at  the  hip-joint,  and  it  is  that  which  I  have  myself  employed  in  the 
four  fuses  in  which  I  have  had  occasion  to  perform  this  operation.  The  flaps 
are  similar  in  shape  and  size  to  those  made  by  Beclard's  method,  but  they  are 


AMPUTATION    AT    THE    HIP-JOINT. 


673 


cut  from  without  inwards,  and  can  thus  be  formed  more  regularly.  A  com- 
paratively small  knife  is  employed — a  four-inch  blade  is  quite  sufficient — and 
the  posterior  flap  should  be  made  first  that  its  line  may  not  be  obscured  by 
bleeding  from  the  anterior.  The  incision  is  begun  a  little  above  the  tro- 
chanter, carried  downwards  and  across  the  back  of  the  limb  in  a  curved 
line  convex  downwards,  and  terminated  in  front  of  the  tuber  ischii ;  the 
anterior  flap  is  marked  out  by  a  corresponding  incision  beginning  and  ending 
at  the  same  points,  and  crossing  the  front  of  the  thigh  at  least  five  inches 
below  the  joint.  The  skin  having  retracted,  the  muscles,  first  of  the  back 
and  "afterwards  of  the  front  of  the  limb,  are  divided  in  an  oblique  manner 
from  below  upwards  (Fig.  197)  till  the  joint  is  reached,  when  disarticulation 

Fig.  197. 


Amputation  at  hip-joint  by  Guthrie's  method. 


is  affected  in  the  ordinary  manner.     Fig.  198  shows  the  appearance  of  the 
wound  after  the  amputation  has  been  completed.     This  operation  affords  i. 


an 


Fig.  198. 


Wound  resulting  from  hip-joint  amputation  by  Guthrie's  method. 

excellent  stump,  with  a  small  and  well-protected  cicatrix,  as  seen  in  Fig. 
199,  from  the  photograph  of  a  patient  whose  thigh  I  amputated  at  the  hip- 
joint  for  a  very  large  osteo-sarcoma,  some  years  since  at  the  Episcopal  Hospital. 
vol.  i.— 43  *       F  F 


674 


AMPUTATIONS. 


Result  of  hip-joint  amputation  by  Guthrie's  method. 


Fig.  199.  Lateral  Flap  Method.— In  tins  form 

of  operation,  the  flaps,  as  the  name  im- 
plies, are  taken  from  the  sides  of  the  limb 
instead  of  from  its  front  and  back.  Here, 
too,  we  may  enumerate  three  varieties  of 
the  operation,  viz.,  Larrey's,  Lisfranc's, 
and  Dupuytren's. 

Larrey's  Method. — Larrey  began  by 
exposing  and  tying  the  femoral  artery 
just  below  Poupart's  ligament.  The  sur- 
geon introduces  the  point  of  his  knife  on 
the  front  of  the  limb,  a  few  fingers' 
breadth  to  the  inner  side  of  and  below 
the  anterior  iliac  spine,  pushes  it  back- 
wards till  it  strikes  the  anterior  face  of 
the  bone,  then  inclines  it  towards  the 
median  line  of  the  body,  so  as  to  graze 
the  inner  surface  of  the  cervix  femoris, 
and,  finally,  effects  transfixion  below  the 
tuber  ischii.  An  internal  flap,  four  inches 
long,  is  next  cut,  as  in  Delpeeh's  method, 

and,  after  disarticulation,  a  corresponding  external  flap  is  cut  in  the  same 

manner. 

The  elder  Blandin's  method  differed  from  Larrey's  simply  in  the  formation 

of  both  flaps  before  attempting  disarticulation. 

Lisfranc's  Method. — In  this  operation,  the  surgeon  employs  a  double- 
edged  knife,  transfixes  on  the  outer  side  of  the  femur,  and  thus  cuts  the  ex- 
ternal flap  before  the  internal.  As  each  flap  is  formed,  he  proceeds  to  tie 
the  bleeding  vessels,  before  proceeding  to  the  other  steps  of  the  operation. 

Dupuytren's  Method. — This  differs  from  Larrey's  method  in  that  the  inter- 
nal flap  is  cut  from  without  inwards,  the  joint  being  then  opened  and  the 
head  of  the  femur  turned  out,  when  the  external  flap  is  made  in  the  ordinary 
manner. 

These  lateral  flap  operations  give  rather  unwieldy  stumps,  and  seem  to  me 
less  desirable  than  the  other  methods  which  have  been  described  in  the  pre- 
ceding pages. 

The  most  pressing  risk,  in  any  amputation  at  the  hip-joint,  is  that  of 
hemorrhage,  for  a  very  few  jets  from  the  femoral  artery  will  reduce  any 
patient  to  a  state  from  which  he  is  not  likely  to  rally.  Hence  special  pre- 
cautions should  invariably  be  adopted  against  bleeding,  in  this  operation.  As 
already  mentioned,  Larrey  directed  that  the  main  vessel  should  always  be 
tied  in  the  groin  as  a  preliminary  step  to  hip  amputation,  and  if  there  be  no 
efficient  means  at  hand  for  restraining  hemorrhage  during  the  operation,  such 
a  course  will  be  found  advantageous.  But  under  ordinary  circumstances,  it 
is,  I  think,  better  to  dispense  with  preliminary  ligation  ;  the  separation  of  the 
vessel  from  the  surrounding  tissues,  which  is  unavoidable  when  an  artery  is 
tied  in  its  continuity,  cannot  but  expose  the  patient  to  more  danger  of  sec- 
ondary hemorrhage,  following  the  operation,  than  when  the  cut  end  of  the  ves- 
sel is  simply  picked  up  with  tenaculum  or  forceps  as  in  other  cases.  Hence, 
when  it  is  practicable,  I  advise  that  the  surgeon  should  rely  upon  compression 
with  an  aortic  tourniquet  or  other  mechanical  means  of  controlling  the  cir- 


AMPUTATION   AT    THE   HIP-JOINT.  675 

dilation,  or,  if  these  are  wanting,  that  lie  should  trust  to  manual  pressure 
exercised  by  intelligent  assistants.  The  simplest  and  best  form  of  aortic 
tourniquet  is  that  of  Prof.  Lister  (Fig.  112) ;  the  instrument  employed  by 
Prof.  Joseph  Pancoast  (who  was  the  first  to  use,  in  1860,  mechanical  com- 
pression for  restraining  hemorrhage  during  this  operation)  is  equally  efficient, 
but  more  complicated  and  less  readily  adjusted.  Prof.  Spence  prefers  to 
compress  the  aorta  by  simply  laying  over  it  a  thick  pin-cushion,  and  keeping 
it  in  place  by  the  pressure  of  an  elastic  bandage  which  is  made  to  surround 
the  body. 

Although  there  can  be  no  question  as  to  the  advantage  derived  from  the 
use  of  the  aortic  compressor  in  hip-joint  amputations,  yet,  at  the  same  time, 
the  pressure  which  must  necessarily  be  made  upon  the  nervous  structures  of 
the  abdomen,  cannot  but  be  undesirable,  if  not  actually  harmful ;  hence  no 
time  should  be  lost  in  securing  the  vessels  after  the  limb  has  been  severed,  so 
that  the  abdominal  compression  may  be  relaxed  as  soon  as  possible.  The 
point  at  which  the  pad  of  the  tourniquet  is  to  be  placed,  is  on  a  level  with 
the  navel,  and  usually  somewhat  to  its  left  side ;  but  as  the  line  of  the  aorta 
varies  in  different  subjects,  this  must  be  determined  by  feeling  for  the  pulsa- 
tion before  adjusting  the  instrument.  If  the  pad  be  properly  placed,  a 
moderate  degree  of  pressure  will  be  sufficient ;  it  is  not  necessary  to  screw  the 
tourniquet  "  home,"  but  merely  to  exercise  enough  force  to  completely  arrest 
the  pulsation  in  both  iliac  arteries.  Before  screwing  down  the  pad,  the  patient 
should  be  gently  rolled  over  upon  his  right  side,  so  that  his  bowels  (which 
should  have  been  emptied  by  a  cathartic  and  an  enema)  may  fall  away  from 
the  line  of  pressure. 

If  manual  compression  is  to  be  employed,  this  may  be  applied  over  the 
aorta  (if  the  patient  be  thin),  over  the  external  iliac,  or  over  the  common 
femoral  artery.  The  hands  of  an  assistant,  too,  should  follow  the  operator's 
knife,  and  should  seize  the  artery  in  the  anterior  flap,  before,  or  at  least,  as 
soon  as,  it  is  divided.  Dr.  Woodbury,  of  Philadelphia,  and  Prof.  Van  Buren, 
of  New  York,  have  suggested,  quite  independently  of  each  other,  that  the 
circulation  might  be  controlled,  during  this  operation,  by  an  assistant  intro- 
ducing his  hand  into  the  patient's  rectum,  and  exercising  direct  pressure  upon 
the  iliac  artery.  Following  out  the  same  idea,  Mr.  P.  Davy,  of  London, 
has  devised  an  ingenious  "  lever,"  to  be  introduced  into  the  rectum  for  the 
same  purpose,  and  a  number  of  cases  of  hip  amputation  have  now  been 
reported  in  which  Davy's  lever  has  proved  most  efficient  in  preventing  bleed- 

Not  only  is  it  essential  that  the  circulation  should  be  controlled  on  the 
cardiac  side  of  the  seat  of  operation,  but  it  is  very  desirable  that  the  patient 
should  not  lose  the  blood  which  is  in  the  limb  to  be  amputated.  To  meet 
this  indication,  Prof.  Erskine  Mason,  of  New  York,  advises  that  the  part 
should  be  first  rendered  bloodless  by  the  use  of  Esmarch's  bandage  and  tube, 
and  that  the  latter  should  be  kept  in  place  during  the  operation,  so  as  to  pre- 
vent the  blood  from  re-entering  the  condemned  limb  ;  all  that  is'lost  will  then 
be  the  blood  between  the  elastic  tube  and  the  point  of  aortic  compression. 
The  practice  thus  suggested  by  Dr.  Mason,  I  look  upon  as  one  of  the  greatest 
improvements  which  has  ever  been  effected  in  the  operation ;  I  have  adopted 
it  myself  with  entire  satisfaction,  and  strongly  urge  its  employment  when- 
ever hip  amputation  is  required. 

A  broad,  flat  sponge  should  also  be  provided,  as  recommended  by  Mr. 
Butcher,  of  Dublin,  for  application  to  the  whole  posterior  flap  while  the  sur- 
geon is  engaged  in  securing  the  principal  vessels,  which  are  in  the  anterior. 
After  the  operation,  the  stump  should  be  closed  in  the  customary  manner, 


676 


AMPUTATIONS. 


suitable  compresses  being  adjusted  so  as  to  keep  the  deep  parts  of  the  wound 
in  apposition. 

The  statistics  of  amputation  at  the  hip-joint  have  been  investigated  by 
various  surgeons,  among  whom  I  may  particularly  mention  Prof.  Stephen 
Smith,  of  New  York;  Mr.  W.  Sands  Cox,  of  Birmingham ;  the  late  Dr.  G. 
A.  Otis,  of  the  United  States  Army;  and  Dr.  A.  Liming,  of  Zurich.  Dr.  F. 
C.  Sheppard,  of  Philadelphia,  has  at  my  request  made  extensive  researches 
into  the  literature  of  the  subject,  and  has  succeeded  in  collecting  633  cases  of 
this  operation,  the  details  of  which  he  has  arranged  for  me  in  tabular  form. 
These  statistics  are  much  more  comprehensive  than  any  which  have  hitherto 
been  published,  and  show  very  conclusively  the  gravity  of  the  operation,  par- 
ticularly in  traumatic  cases. 

The  following  summaries  show  the  results  of  the  operation  (1)  in  military 
practice;  (2)  in  cases  of  injury  treated  in  civil  life;  (3)  in  cases  of  disease; 
(4)  in  cases  the  nature  of  which  is  not  certainly  known  ;  and  (5)  in  cases  of 
all  kinds  taken  together. 

I.  Summary  of  Two  Hundred  and  Thirty-eight  Cases  of  Hip-joint 
Amputation  in  Military  Practice. 


Nature  of  operation. 


Primary       .... 

Intermediate 

Secondary   .... 

Re-amputation  of  thigh  stump 

Not  stated   .... 


Total  number  of  cases 


Recov- 

Died. 

Undeter- 

Total. 

ered. 

mined. 

7 

89 

0 

96 

4 

59 

0 

63 

10 

17 

0 

27 

4 

3 

0 

7 

5 

39 

1 

45 

30 

207 

1 

238 

Mortality 
per  cent.1 


92.7 
93.6 
62.9 

42.8 
88.6 


87.3 


II.  Summary  of  Seventy-one  Cases  of  Hip-joint  Amputation  for  Injury  in 

Civil  Practice. 


Nature  of  operation. 


Primary     .... 

Intermediate 

Secondary  .... 

Re-amputation  of  thigh  stump 

Not  stated 


Total  number  of  cases 


Recov- 
ered. 


24 


25 
7 
6 

1 


47 


31 
12 
11 
5 
12 


71 


Mortality 
per  cent. 


80.6 
58.3 
54.5 
20.0 
66  6 


66.1 


III.  Summary  of  Two  Hundred  and  Seventy-six  Cases  of  Hip-joint 
Amputation  for  Disease. 


Natnre  of  operation. 


Amputation  of'entire  limb  . 
Re-amputation  of  thigh  stump 


Total  number  of  cases 


Recov- 
ered. 


136 

20 


156 


Died. 


95 
10 


105 


Undeter- 
mined. 


14 
1 


15 


Total. 


245 

31 


276 


Mortality 
per  cent.1 


41.1 
33.3 


40.2 


Undetermined  cases  omitted  in  computing  percentages. 


AMPUTATION    AT    THE    HIP-JOINT. 


677 


IV.  Summary  of  Forty-eight  Cases  op  IIip-joint  Amputation  for 

Unknown  Causes. 


Number  of  cases , 


Recov- 
ered. 

Died. 

Undeter- 
mined. 

Total. 

10 

34 

4 

48 

Mortality 
per  ceut.1 

77.2 


V.  General  Summary  of  Sin  Hundred  and  Thirty-three  Cases  of  Hip-joint 

Amputation  for  all  Causes. 


Nature  of  case. 

Recov- 
ered. 

Died. 

Undeter- 
mined. 

Total. 

Mortality 
per  cent.1 

156 
54 
10 

105 

254 

34 

15 
1 

4 

276 
309 

48 

40.2 
82.4 
77.2 

220 

393 

20 

633 

64.1 

From  the  preceding  statistics  it  will  be  seen  that,  in  military  practice,  the 
death-rate  of  primary  and  of  intermediate  amputation  has  reached  the 
appalling  figure  of  93  per  cent,,  or,  in  other  words,  that  not  one  patient  in 
fourteen  recovers  from  the  operation.  In  civil  practice,  the  results  of  primary 
amputation  are  still  very  unfavorable,  the  mortality  being  over  80  per  cent., 
or  but  one  patient  in  five  recovering.  Hence  the  inference  is  irresistible 
that,  except  in  very  exceptional  circumstances,  as  where  the  limb  is  entirely 
carried  away  by  a  round  shot,  or  completely  crushed  at  a  point  too  high  for 
amputation  in  its  continuity,  or  where,  besides  the  injury  to  the  bone,  the 
great  vessels  are  severed — in  other  words  wrhere  the  patient  is  threatened 
with  instant  death  as  the  result  of  his  injury — primary  amputation  at  the 
hip-joint  should  be  avoided.  Whenever  there  is  the  slightest  chance  of  doing 
so,  an  effort  should  be  made  to  tide  the  patient  over  the  immediate  risks  of 
the  injury  by  expectant  and  palliative  measures,  keeping  amputation  in 
reserve,  if  necessary,  as  a  secondary  operation.  Secondary  hip-joint  ampu- 
tation, though  very  grave,  is  comparatively  a  successful  procedure,  the  mor- 
tality, in  civil  and  military  cases  taken  together,  being  somewhat  over  60  per 
cent.,  or  two  patients  out  of  five  recovering.  In  non-traumatic  cases  (opera- 
tions for  necrosis,  tumors,  etc.),  the  results  are  still  more  favorable,  the  death- 
rate  being  less  than  41  per  cent.,  or  three  out  of  five  patients  recovering. 
Taking  all  cases  together,  the  mortality  is  seen  to  be  64.1  per  cent.,  as  com- 
pared with  a  death-rate  of  63.8  per  cent,  for  all  amputations  through  the 
continuity  of  the  thigh,2  thus  confirming  the  general  rule  that  the  gravity 
of  amputation  increases  as  the  site  of  operation  is  in  closer  proximity  to  the 
trunk. 

In  every  class  of  cases,  but  particularly  in  cases  of  injury,  re-amputation 
after  previous  amputation  through  the  thigh,  is  much  less  fatal  than  when 
the  whole  lower  extremity  is  removed  at  once;  this  is  easily  understood  when 
we  reflect  that  the  shock  to  the  system  of  such  a  re-amputation  is  necessarily 
much  less  severe  than  when  the  patient,  seeking  to  avoid  imminent  death, 
submits  to  what  Hennen3  calls  the  "  tremendous  alternative"  of  losing  at  one 
operation  nearly  a  fourth  of  the  whole  body. 

1  Undetermined  cases  omitted  in  computing  percentages. 

2  See  Table,  page  630.  8  Op.  cit.,  p.  30. 


678 


AMPUTATIONS. 


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INDEX. 

YOL.  I. 


ABSCESS,  117 
Accidents  of  anaesthesia,  412,  415 
Acetic  ether,  432 
Acid,  carbolic,  430 
Actual  cautery,  504 
Acupuncture,  502 
Administration  of  anaesthetics,  412 

of  chloroform,  446 

of  ether,  443 
Age,  effect  of,  in  amputation,  618 
in  anaesthesia,  414 
in  operations,  459 
in  shock,  359 

in  surgical  diagnosis,  339 
Agnew,  surgical  diagnosis,  337 
Air  in  veins  after  operations,  476 

dressing  of  stump,  594 

passages,  effect  of  anaesthetics  on,  406 
erysipelas  of,  201 
Alcohol  in  erysipelas,  198 
Alcoholism,  322 
Alcohols,  430 
Aldehydes,  432 

Allen's  method  of  transfusion,  512 
Ammonia  in  shock,  373 
Amputation  or  amputations,  551 

advantages  of  different  methods,  589 

at  ankle,  656 

of  arm,  642 

for  avulsion  of  limb,  559 

Carden's,  665 

cases  of,  612 

Chopart's,  653 

circular  operation,  579 
history  of,  556 

for  compound  fractures  and  luxations,  560 

conditions  calling  for,  559  et  seq. 

for  deformities,  564 

for  disease  of  bones  and  joints,  564 

for  dry  gangrene,  563 

effect  of  age  in,  618 

of  constitutional  condition,  622 


Amputation — 

for  effects  of  heat  and  cold,  562 

effect  of  hygienic  surroundings  on,  623 

of  nature  of  lesion  on,  625 

of  part  involved  on,  629 

of  period  of,  627 

of  sex  on,  622 
at  elbow,  640 
elliptical  operation,  583 
erysipelas  in,  624 
of  fingers,  631  et  seq.  • 

flap  operation  in,  558 
double,  585 
single,  584 
of  foot,  650 
of  forearm,  639 
Gritti's,  665 

for  gunshot  injuries,  561 
Hancock's,  655 
of  hand,  634 
Hey's,  652 
at  hip-joint,  669 
history  of,  552  et  seq. 
for  hospital  gangrene,  563 
instruments  for,  565 
at  knee,  663,  665 
at  knee-joint,  663 

for  lacerated  and  contused  wounds,  560 
Langenbeck's  method,  587 
Lee's,  662 
Le  Fort's,  659 
of  leg,  660 

for  lesion  of  arteries,  562 
ligature  in,  554 
Lisfranc's,  652 
Lister's  method,  5S8 
Malgaigne's  method,  584 
at  medio-tarsal  joint,  653 
at  metacarpus,  635,  636 
at  metatarsus,  650  et  seq. 
modified  circular  operation,  582 
for  morbid  growths,  564 

(703) 


704 


INDEX. 


Amputation — 

mortality  and  causes  of  death  after,  610 

for  mortification,  562 

operative  methods  employed  in,  579  et  seq. 

oval  operation,  584 

Pirogoff's,  658 

pyaemia  in,  624 

Ravaton's  method,  585 

Roux's,  658 

Scoutetten's  method,  584 

Sedillot's  method,  586,  661 

above  shoulder,  647 

at  shoulder,  643 

simultaneous,  590 

special,  of  lower  extremity,  649  et  seq. 

of  upper  extremity,  631  el  seq. 
Stokes's,  666 
subastragaloid,  654 
Syme's  656 

synchronous,  590,  592 
Teale's  method,  587 
for  tetanus,  564 
of  thigh,  667 
of  thumb,  634 
of  toes,  649 
tourniquet  in,  553 
Tripier's,  655 
Vermale's  method,  585 
at  wrist,  637 
Aniyl  chloride,  429 
iodide,  429 
nitrite,  429 
Amylene,  425 
Amyloid  degeneration,  62 
Anaeinia,  3 

Anaesthesia,  403.     See  also  Anaesthetics, 
accidents  of,  412,  415 
after-treatment  of,  445 
artificial,  mortality  from,  422 
asphyxia  during,  412 
from  compression,  422 
in  dentistry,  417 
by  electricity,  419 
history  of,  403 

influence  of  age,  sex,  and  temperament 
on,  414 
of  cerebral  and  spinal  diseases  on,  414 
of  excitement  or  terror  on,  415 
of  intra-thoracic  diseases  on,  415 
of  rate  of  inhalation  on,  414 
from  intravenous  injections,  419 
local,  418,  447 
meaning  of,  4<>3 
in  obstetrics,  416 
In  operations,  441 
phenomena  of,  406 
physiology  of,  409 


Anaesthesia — 

post-mortem  appearances  after  death  from, 

423 
by  rapid  respiration,  419 
in  surgery,  416 
syncope  during,  412 
by  various  methods,  419,  448 
Anaesthetic  mixtures,  420 

substances,  424 
Anaesthetics,  403 

administration  of,  412 
effect  of,  on  action  of  heart,  408 
on  air  passages,  406 
on  brain,  407 
on  eyes,  406 

on  general  sensibility,  406 
on  muscular  movements,  407 
on  nervous  centres,  414 
on  power  of  volition,  407 
on  reflex  action,  408 
on  respiration,  408 
on  secretions,  408 
on  temperature,  408 
employment  of,  416 
in  shock,  374 
Aneurism  of  aorta,  329 

of  stumps,  604 
Ankle,  amputation  of,  656  et  seq. 
Anodynes  in  inflammation,  156 
Antecedent  history  in  surgical  diagnosis,  341 
Antiseptic  dressing  of  stumps,  597 
Antiseptics  in  inflammation,  159 
Aorta,  aneurism  of,  329 
Aran's  ether,  428 
Arm,  amputation  of,  642 
Arteries,  amputation  for  lesion  of,  562 

influence  of,  on  operation,  463 
Arterial  atheroma,  329 

transfusion,  513 
Arteriotomy,  509 
Artery  forceps,  574 
Arthritism,  311 

Artificial  limbs,  adaptation  of,  606 
respiration,  514  et  seq. 
in  shock,  372 
Ashhurst,  amputations,  551 
Asphyxia  during  anaesthesia,  412 
Aspiration,  519 

pneumatic,  595 
Assistants  during  operations,  449 
Astringents  in  erysipelas,  194 

in  inflammation,  157 
Atheroma,  arterial,  329 
Aural  symptoms  in  scurvy,  300 
Auto-transfusion,  513 
Aveling's  method  of  transfusion,  510 
Azoturia,  331 


INDEX. 


705 


BANDAGE  or  bandages,  483 
circular,  485 

crossed  or  oblique  of  angle  of  jaw,  494 
figure-of-eight,  491 

of  chest,  anterior,  491 

posterior,  491 
of  elbow,  491 
of  head  and  jaw,  493 
handkerchief,  497 
hardening,  498 
for  head,  493 

many  tailed,  of  Scultetus,  497 
oblique,  485 
plaster  of  Paris,  498 
recurrent,  of  head,  494 

of  stumps,  495 
roller,  483 

sling  or  four  tailed,  496 
special,  485 
spica,  488 

of  foot,  490 
of  groin,  489 
of  both  groins,  490 
of  shoulder,  489 
of  thumb,  489 
spiral,  485,  486 
of  chest,  488 
of  fingers,  4S6 

of  hand,  or  demi-gauntlet,  486 
of  penis,  488 
reversed,  485 

of  lower  extremity,  487 

of  upper  extremity,  486. 

despensory  and  compressor,  of  breast,  492 

of  both  breasts,  493 
T  double,  496 
T  single,  496 
use  of,  483 
V  of  head,  495 
Velpeau's,  493 
Bandaging,  general  rules  for,  484 
Basis-substance,  vital  processes  in,  34 
Beclard's  amputation  at  hip-joint,  672 
Belladonna  in  shock,  373 
Benzene,  425 

Bert  on  skin-grafting,  546 
Bilious  erysipelas,  186 
Bisulphide  of  carbon,  433 
Bites  of  serpents,  delirium  from,  3S4 

and  stings  of  insects,  delirium  from,  385 
Bladder,  care  of,  after  operations,  454 
Bleeding.     See  Venesection  and  Blood-letting, 
from  external  jugular,  509 
from  internal  saphena,  509 
Blood,  clot  of,  causing  inflammation,  79 

defect    in  quality  of,   causing  inflamma- 
tion, 70 

VOL.  I. 45 


Blood- 
examination  of,  in  pysemia,  205 

poison  in,  causing  inflammation,  71 

transfusion  of,  509 
direct,  510 
Blood-letting,  505 

in  erysipelas,  193 

in  inflammation,  149 
Blood-poisoning,  106 
Bloodvessels,  contractile  elements  of,  4 
Bloody  cupping,  506 
Blunt  knives  in  operations,  451 
Bone  forceps,  573 

hypertrophy  of,  in  stumps,  606 

nippers,  573 

suppurative  inflammation  in,  38 
Bones,  amputation  for  disease  of,  564 

of  head,  changes  in,  in  rachitis,  260,  264 

of  lower  extremity,  changes  in,  in  rachi- 
tis, 267 

of  trunk,  changes  in,  in  rachitis,  264,  265, 
267 

of  upper  extremity,  changes  in,  in  rachi- 
tis, 266 
Bordeaux  dressing  of  stumps,  598 
Bowel  affections,  influence  of,  on  operations, 

467 
Bowels,  care  of,  after  operations,  454 

in  scurvy,  292 
Brain,  effect  of  anaesthetics  on,  407 
Brinton,  operative  surgery  in  general,  435 
Bromide  of  ethyl,  428 
Bryant  on  skin-grafting,  543 
Burns,  delirium  from,  3S9 
Bursae  in  stumps,  606 
Butlin,  scrofula  and  tubercle,  231 
Butylchloral  hydrate,  430 


CACHECTIC   conditions  causing  erysipelas, 
163 
Cachexia,  influence  of,  on  operations,  468 

scorbutic,  295 
Calcareous  degeneration,  62 
Cancer,  313 

Capillaries,  contractility  of,  5 
Carbolic  acid,  430 

in  erysipelas,  197 
Carbon  bisulphide,  433 
Carbonic  acid,  433 

oxide,  433 

tetrachloride,  426 
Carden's  amputation,  665 
Cardism,  329 
Caries  in  stumps,  605 

Cartilage,  suppurative  inflammation  in,  38 
Cartilaginous  changes  in  rachitis,  257 


706 


INDEX. 


Catalepsy,  delirium  from,  392 
Catarrhal  inflammation,  132 
Cathartics  in  inflammation,  157 
Cautery,  504 

galvanic,  523 

Paquelin's,  505 
Cell-nucleus,  42 
Cells,  apparent  migration  of,  34 

fixed,  new  observations  on,  51 

of  glands,  contractility  of,  9 
Cellulitis,  diffuse,  of  stumps,  602 
Cerebral  disease,  effect  of,  in  anaesthesia,  414 

symptoms  in  scurvy,  299 
Charpie,  479 
Chemical  irritants  causing  inflammation,  80 

theory  of  pyaemia,  204 
Chloral  hydrate,  430 
Chloride  of  amyl,  429 
Chloroform,  426 

administration  of,  446 

compared  with  ether,  442 

first  insensibility  from,  431 

history  of,  405 

mortality  from,  422.  433 
Chopart's  amputation,  653 
Chorea,  delirium  from,  385 
Circular  amputation,  579 
Circulation,  investigation  of,  in  surgical  diag- 
nosis, 347 
Climate  causing  inflammation,  73 
Clinical  thermometer,  348,  527 
Clot  of  blood  causing  inflammation,  79 
Coagulable  lymph,  110 
Cohnheim's  theory  of  inflammation,  25 
Cold,  amputation  for  effects  of,  562 

a  cause  of  erysipelas,  163 
of  inflammation,  74 

in  erysipelas,  194 

in  inflammation,  144 
Colloid  degeneration,  62 
Color  in  surgical  diagnosis,  345 
Compresses,  480 
Compression  causing  anaesthesia,  422 

in  inflammation,  147 
Connective  substance,  comparison  of,  with  sup- 
posed fibrillar  substances,  43 
Constitutional  conditions,  classification  of,  307 
effect  of,  in  amputation,  622 

in  operations,  463 
and  injuries,  reciprocal  effects  of,  307 
influence  of,  308 
Contagion  of  erysipelas,  165 
Contractile  elements  of  bloodvessels,  4 
Contractility  <>{  capillaries,  5,  !> 
<'(,ntusc<i  wounds,  amputation  for,  560 

Contusion  c;nisiii(,'  inflammation,  78 
Coste  on  skin-grafting,  543 


Cotton,  480 

dressing  for  stumps,  598 
Counter-irritation,  500 

in  inflammation,  153 
Cranial  bones,  changes  in,  in  rachitis,  260 
Craniotabes,  261 

symptoms  of,  262 
Croupous  exudation,  109 
Cupping,  505 
Cutis,  suppurative  inflammation  in,  38 

transplantation  of,   58.      See  also   Skin- 
grafting. 


DEFORMITIES,  amputation  for,  564 
Deformity  in  rachitis,  260 
Degeneration,  amyloid,  62 
calcareous,  62 
colloid,  62 
fatty,  61 
of  tissues,  61 
Delafield,  pyaemia  and  allied  conditions,  203 
Delirium,  anatomy  of,  380 

from  bites  of  serpents,  384 

and  stings  of  insects,  385 
from  burns  and  scalds,  389 
from  catalpsy,  392 
from  chorea,  385 
connection  of,  with  insanity,  379 
definition  of,  379 
from  embolism,  382 
from  epilepsy,  392 
from  erysipelas,  391 
from  hectic  fever,  392 
from  hemorrhage,  381 
from  hydrophobia,  385 
from  lacerated  wounds,  387 
from  lesions  of  nerves  of  special  sense,  3S3 
after  operations,  475 
from  pyaemia,  phlebitis,  etc.,  393 
from  shock,  382 
from  surgical  operations,  385 
from  surgical  or  traumatic  fever,  385 
from  tetanus,  385 
traumatic,  379 
causes  of,  381 
treatment  of,  394 
Delirium  tremens,  323,  394 
causes  of,  395 

connection  of,  with  mania-a-potu,  397 
diagnosis  of,  399 
symptoms  of,  397 
treatment  of,  401 
Dentistry,  anaesthesia  in,  417 
Dentition,  effect  of  rachitis  on,  268 
Depressants  in  inflammation,  158 
Destructive  inflammation,  112,  115 


INDEX. 


707 


Diabetes,  alcoholic,  331 

mellitus,  330 
Diagnosis,  surgical,  337 

age  in,  339 

antecedent  history  in,  341 

circulation  in,  347 

color  in,  340 

difficulties  of,  338 

digestive  apparatus  in,  352 

duration  of  disease  in,  343 

expression  of  parts  in,  343 

genito-urinary  system  in,  354 

habits  in,  340 

interrogation  of  internal  organs   in, 
347 

mensuration  in,  346 

mental  and  moral  states  in,  342 

mobility  in,  345,  351 

movements  in,  346 

nervous  system  in,  350 

occupation  in,  340 

pain,  significance  of,  in,  351 

personal  examination  in,  343 
history  in,  341 

posture  or  attitude  in,  343 

residence  in,  343 

respiration  in,  349 

sex  in,  339 

smell  in,  347 

social  condition  in,  342 

sound  in,  346 

special  examination  in,  343 

temperature  in,  345 

thermometry  in,  348 

touch  in,  345 

ti'nnslucency  in,  345 

weight  in,  345 
Diathesis,    hemorrhagic,    in   operations,   470. 

See  Haemophilia. 
Dichlorethane,  427 
Diet  in  inflammation,  154 
after  operations,  453 
Digestive   apparatus    in    surgical    diagnosis, 

352 
Digitalis  in  shock,  373 
Dissecting  forceps,  578 
Dog,  rabies  in,  216 
Donnelly  on  skin-grafting,  594 
Drainage  in  inflammation,  152 

after  operations,  451 
Dressing  or  dressings,  choice  of,  310 

fixed,  498 

after  operations,  451 

of  stump,  593  et  seq. 

surgical,  479 
Drunkenness,  influence  of,  on  operations,  458 
Dry  cupping,  505 


Dupuytren's  amputation  at  hip-joint,  674 
at  shoulder-joint,  645 


EARTH  dressing  of  stumps,  598 
Effleurage,  525 
Elbow,  amputation  at,  640 
Electricity  as  an  anaesthetic,  419 

surgical  uses  of,  521 
Electrolysis,  522 
Elliptical  amputation,  583 
Emboli,  mechanical  and  infectious,  in  pyaemia, 

211 
Embolism,  delirium  from,  382 

fatty,  374 

after  operations,  475 

in  scurvy,  299 
Emetics  in  erysipelas,  197 
Endothelium,  55 
Epididymitis  in  scrofula,  245 
Epilepsy,  330 

delirium  from,  392 
Epithelium,  55,  56 
Erysipelas,  161 

of  air-passages,  treatment  of,  201 

in  amputations,  624 

astringents  in,  194 

bilious,  186 

blood-letting  in,  193 

carbolic  acid  in,  197 

causes  of,  162  et  seq. 

illustrated  by  history  of  epidemic  out- 
breaks of  disease,  168 

cold  in,  194 

contagion  of,  165 

delirium  from,  391 

diagnosis  of,  188 

emetics  in,  197 

epidemic,  connection  of,   with  puerperal 
fever,  173 
treatment  of,  201 

of  face  and  scalp,  184 

gangrenous,  183 

history  of,  161 

incisions  in,  196 

iodine  in,  195 

iron,  tincture  of  chloride  of,  in,  199 

metastatic,  186 

morbid  anatomy  of,  176 

of  new-born  infants,  186 

nitrate  of  silver  in,  195 

oedematous,  183 

after  operations,  477 

phlegmonous,  182 
prognosis  of,  188 
prophylaxis  of,  190 
punctures  in,  196 


708 


INDEX. 


Erysipelas — 

purgatives  in,  197 

quinine  in,  198 

specific  cause  of,  167 

stimulants  in,  194 
alcoholic,  198 

of  stump,  602 

symptoms  of,  177 

synonyms  of,  161 

temperature  in,  179 

treatment  of,  191 

in  infants  and  old  persons,  201 
internal,  197 
surgical,  195 

unity  of  various  types  of,  170 

wandering,  178 
Erysipelatous  peritonitis,  187 
Esmarch's  apparatus,  569 
Ethane,  424 
Ether  or  ethers,  431 

acetic,  432 

administration  of,  412,  443 

Aran's,  428 

compared  with  chloroform,  442 

first  insensibility  from,  431,  443 

formic,  432 

history  of,  404 

hydrochloric,  427 

hydriodic,  429 

methylic,  431 

mortality  from,  423 

nitric,  431 
Ethereal  salts,  431 
Ethyl  bromide,  428 
Ethylene,  425 
Examination  of  patient,  339 

personal,  in  surgical  diagnosis,  343 

special,  in  surgical  diagnosis,  343 
Excitement,  prostration  with,  363 
Expediency,  operations  of,  439 
Expression  of  parts  in  surgical  diagnosis,  343 
Extravasations  in  scurvy,  297 
Exudation,  active  and  passive,  107 

croupous,  109 

inllammatory,  106 

of  plastic  lymph,  108 
Eyes,  effect  of  anaesthetics  on,  406 


FARADIZATION,  525 
Fatty  degeneration,  61 
embolism,  374 
Fever,  hectic,  129 

delirium  from,  392 
infective  and  aon-infective,  105 
nature  of,  102 
in  scurvy,  300 


Fever — 

surgical,  traumatic,  or  inflammatory,  99, 
455 
causes  of,  103 
delirium  from,  385 
phenomena  of,  100 
treatment  of,   456 
Fibres,  muscular,  transversely  striped,  44 

smooth  muscular,  47 
Fibrilla?,  nature  of,  44,  51 

theory  of,  41 
Figure-of-eight  bandage,  491 
Fingers,  amputation  of,  631  et  seq. 
First  intention,  healing  by,  57 

union  by,  111 
Fixed  cells,  supposed,  new  observations  on,  51 

dressings,  498 
Flap  amputation,  558,  584,  585 
Foetal  rachitis,  253 
Food,  defects  of,  causing  scurvy,  289 
Foot,  amputation  of,  650 
Fokbes,    hydrophobia   and    rabies,   glanders, 

malignant  pustule,  215 
Forceps,  artery,  573 
bone,  573 
dissecting,  578 
Forearm, amputation  of,  639 
Foreign  material  in  wound  causing  inflamma- 
tion, 76 
Formic  ether,  432 
Fractures,  compound,  amputation  for,  560 

delirium  from,  387 
Function,  impaired  or  abolished,  in  inflamma- 
tion, 99 
Fungi,  microscopic,  causing  inflammation,  85 


GALVANIZATION,  525 
Galvano-cautery,  523 
Gangrene,  121,  137 

amputation  for,  563 
after  operations,  476 
in  stumps,  602 
Gangrenous  erysipelas,  1S3 
Genito-urinary  system  in  surgical  diagnosis, 

354 
Germ  theory  of  pyaemia,  205 
Glanders,  225 

diagnosis  of,  227 
prognosis  of,  227 
symptoms  of,  225 
in  horse,  225 
in  man,  226 
treatment  of,  227 
Glue  and  oxide  of  zinc  bandage,  500 
Gluttony,  influence  of,  on  operations,  459 
Goltz's  experiments  on  shock,  366 


INDEX. 


709 


Gonorrhoea  in  scrofula,  245 
Gout,  312 

in  scrofula,  246 
Granulation,  112 

healing  by,  57 
Gritti's  amputation,  665 
Gum  and  chalk  bandage,  500 
Gums  in  scurvy,  291,  296 
Gunshot  injuries,  amputation  for,  561 
Guthrie's  amputation  at  hip-joint,  672 
Gutta-percha  or  rubber  tissue,  482 


HABITS  of  patient  in  operations,  458 
in  surgical  diagnosis,  340 
Haemophilia,  318.    See  Hemorrhagic  diathesis. 
Hall's  ready  method  of  artificial  respiration, 

516 
Hamilton  on  skin-grafting,  539 
Hancock's  amputation,  655 
Hand,  amputation  of,  634 
Handkerchief  bandages,  497 
Hardening  bandages,  498 
Head,  bandages  for,  493 
Healing  by  first  intention,  57 

by  granulation,  57 

under  scab,  111 
Heart,  effect  of  anaesthetics  on,  408t 

influence  of,  on  operations,  463 

in  scurvy,  291 
Heat,  amputation  for  effects  of,  562 

causing  inflammation,  80 

external,  in  shock,  371 

in  inflammation,  97,  146 
Hectic  fever,  129 

delirium  from,  392 
Heitzmann's  observations  on  rachitis,  256 
Hemorrhage,  20 

delirium  from,  381 

in  hip-joint  amputation,  674 

in  operations,  469,  472 

in  scurvy,  298 

from  stumps,  603 
Hemorrhagic  diathesis  in  operations,  470.    See 

Haemophilia. 
Hepatism,  325,  326 
Herpetism,  313 

Hewitt's  method  of  transfusion,  511 
Hey's  amputation,  652 
Hip-joint,  amputation  at,  669 
cases  of,  678 
hemorrhage  in,  674 
Hodgen  on  skin-grafting,  547 
Hospital  gangrene  in  stumps,  602 

hygiene,  influence  of,  on  operations,  471 
Howard's  direct  method  of  artificial    respira- 
tion, 515 


Hunt,  traumatic  delirium  and  delirium  tre- 
mens, 379 
Hcntek,  minor  surgery,  479 
Hydriodic  ether,  429 

Hydrocarbons  and  their  derivatives  as  anae- 
sthetics, 424 
Hydrochloric  ether,  427 
Hydrophobia,  215 

cause  of,  215 

delirium  from,  385 

diagnosis  of,  220 

incubation  of,  217 

morbid  anatomy  of,  219 

prognosis  of,  221 

symptoms  of,  218,  219 

treatment  of,  222 
curative,  223 
preventive,  222 
Hygiene,  hospital,  influence  of,  on  operations, 

471 
Hygienic  surroundings,  effect  of,  in  amputa-^ 
tion,  623 
after  operations,  454 
Hyperemia,  1 

active,  2 

causes  of,  4 

causing  inflammation,  73 

of  irritation,  18 

mechanical,  19 

of  paralysis,  18 

passive,  3 
Hyperplasia,  131 
Hypertrophy,  131 
Hypnotism,  421 
Hypodermic  injection,  518 
Hysteria,  330 


IMMOBILITY  in  inflammation,  142 
*-    Incisions  in  erysipelas,  196 

in  inflammation,  151 
Incubation  of  hydrophobia,  217 
Induration,  131 
Infancy,  operations  in,  334 
Infection  of  tubercle,  236 
Infectious  emboli  in  pyaemia,  211 
Infective  fever,  105 

inflammation,  105 
Inflammation,  65 

absorption  of  poisons  in,  92 

anodynes  in,  156 

antiseptics  in,  159 

astringents  in,  157 

blood  clot  causing,  79 

blood-letting  in,  149 

cardinal  symptoms  of,  23 

catarrhal,  132 


710 


INDEX. 


In  (lamination — 

causes  of,  68,  71 
exciting,  74 
predisposing,  70 
chemical  irritants  causing,  80 
chronic,  130 
climate  causing,  73 
cold,  causing,  74 

in,  144 
compression  in,  147 
contusion  causing,  78 
counter-irritation  in,  153 
from  defect  in  quality  of  blood,  70 
defective    or    deranged    nervous    supply 

causing,  71 
definitions  of,  65 
depressants  in,  158 
destructive,  112,  115 
diet  in,  154 
drainage  in,  152 

foreign  material  in  wounds  causing,  76 
habit  of  body  in,  73 
heat  causing,  SO 
in,  97 

and  moisture  in  treatment  of,  146 
hyperemia  causing,  73 
impaired  or  abolished  function  in,  99 
incisions  in,  151 
infective  and  non-infective,  105 
irrigation  in,  145 
irritation  and  injury  causing,  68 
laxatives  in,  157 
ligation  of  main  artery  in,  154 
mechanical  action  causing,  80 

violence  causing,  78 
mercury  in,  156 
microscopic  fungi  causing,  85 

migration  theory  of,  25 

nursing  in,  154,  155 

pain  in,  98 

parasites  causing,  85 

pathology  of,  1 

period  of  life  in,  72 

from  poison  in  blood,  71 

poisonous  action  of  minerals  causing,  81 

of  plants  causing,  82 

secretion  of  animals  causing,  82 

position  in,  144 

prevention  of,  138,  140 

putrid  substanceB  causing,  90 

quinine  in,  1 56 

redness  in,  96 

rest  and  immobility  in,  142 

revulsion  and  counter-irritation  in,  153 

in  the  scrofulous,  133 

stimulants  in,   155 

bu  ppurative,  in  bone,  38 


Inflammation,  suppurative — 
in  cartilage,  38 
in  connective  substances,  37 
in  cutis,  38 
in  tendon,  37 
theory  of,  25 
swelling  in,  97 
symptoms  of,  95 
in  the  syphilitic,  134 
terminations  of,  135 
theory  of,  25 
treatment  of,  138 
venom  of  serpents  causing,  84 
wounds  causing,  75,  76 
Inflammatory  changes  of  tissues,  24 
exudations,  106 
fever,  99 
Inflation,  mouth  to  mouth,  514 
Injections,  hypodermic,  518 

intravenous,  anaesthesia  from,  419 
of  milk,  etc.,  513 
Injuries  and  constitutional  conditions,  recipro- 
cal influence  of,  308 
Injury  causing  inflammation,  68 
Inorganic  substances  as  anaesthetics,  432 
Insanity,  330 

connection  of  delirium  with,  379 
Insensibility,  first,  from  chloroform,  431 

from  ether,  431,  443 
Instruments  for  operation,  450 
Internal  organs,  interrogation  of,  in  surgical 

diagnosis,  347 
Intravenous  injections,  anaesthesia  from,  419 

of  milk,  etc.,  513 
Iodide  of  amyl,  429 
Iodine  in  erysipelas,  195 
Iodoform,  427 

Iron,  tincture  of  chloride  of,  in  erysipelas,  199 
Irrigation  in  inflammation,  145 
Irritation  causing  inflammation,  68 

hypersemia  of,  18 
Ischaemia,  3 

causes  of,  4 
Issues,  502 


JOHNSTON,  plastic  surgery,  531 
Joints,  amputation  for  disease  of,  564 
in  scurvy,  291 
Jugular,  external,  bleeding  from,  509 


KERATITIS,  suppurative,  28 
Ketones,  432 
Kidneys  in  scurvy,  292,  299 
Kneading,  525 
Knee,  amputation  at,  663,  665 


INDEX. 


711 


Knee-joint,  amputation  at,  663 
Knives,  amputating,  570 

blunt,  in  operations,  451 

LACERATED  wounds,  amputation  for,  560 
Langenbeck's  method  of  amputating,  587 
Larrey's  amputation  at  hip-joint,  674 

at  shoulder-joint,  644 
Laryngismus   stridulus,    connection    of,    with 

rachitis,  263 
Laxatives  in  inflammation,  157 
Leanness,  influence  of,  on  operations,  458 
Leech,  artificial  or  mechanical,  508 
Leeching,  507 
Lee's  amputation,  662 
Le  Fort's  amputation,  659 
Leg,  amputation  of,  660 
Leucocythsemia,  318 
Lewisson's  experiments  on  shock,  369 
Ligation  of  main  artery  in  inflammation,  154 
Ligatures  in  amputations,  575 

invention  of,  554 
Limb,  avulsion  of,  amputation  for,  559 
Limbs,  artificial,  adaptation  of,  606 

pains  in,  in  scurvy,  296 
Lint,  479 
Liquor  puris,  116 
Lisfranc's  amputation,  652 

at  hip-joint,  674 

at  shoulder-joint,  646 
Lister's  method  of  amputating,  588 
Liston's  amputation  at  hrp-joint,  672 
Liver,  influence  of,  on  operations,  467 

in  scurvy,  292,  300 
Local  anaesthesia,  418,  447 
Locality,  influence  of,  on  operations,  463 
Locomotor  ataxia  and  various  neuroses,  329 
Lower  extremity,  special  amputations  of,  649 

et  seq. 
Lungs,  influence  of,  on  operations,  464 

in  scurvy,  292 
Luxations,  compound,  amputation  for,  560 
Lyman,  anaesthetics  and  anaesthesia,  403 
Lymph,  coagulable,  110 
plastic,  110 

exudation  of,  108 


MACKINTOSH,  483 
Malaria,  321 


Malgaigne's  method  of  amputating 

Malignant  pustule,  228 

pathology  of,  229 
symptoms  of,  228 
treatment  of,  229 

Mania-a-potu,  397 

Mansell-Moullix,  shock,  357 


584 


Martin  on  skin  grafting,  546 
Massage,  525 

Maxillae,  changes  in,  in  rachitis,  264 
Mechanical  emboli  in  pyaemia,  211 

hyperemia,  19 
Meche,  481 

Mensuration  in  surgical  diagnosis,  346 
Mental  emotion,  a  cause  of  shock,  358 

and  moral  states  in  surgical  diagnosis,  342 

powers,  impairment  of,  in  scurvy,  296 

preoccupation  and  expectation,  a  cause  of 
shock,  359 
Mercury  in  inflammation,  156 
Metacarpus,  amputations  of,  635,  636 
Metastatic  erysipelas,  186 
Metatarsus,  amputations  of,  650  et  seq. 
Methane,  424 
Methylal,  431 
Methylene  bichloride,  426 
Methylic  chloride,  426 

ether,  431 

iodide,  427 
Migration,  apparent,  of  cells,  34 
Milk,  intravenous  injection  of,  513 
Minerals,  poisonous  action  of,  causing  inflam- 
mation, 81 
Minor  surgery,  479 
Mixtures,  anaesthetic,  420 
Mobility  in  surgical  diagnosis,  345,  351 
Modified  circular  amputation,  582 
Moisture  in  inflammation,  146 
Monochlorotetrane,  429 
Morbid  growths,  amputation  for,  564 
Morphinism,  324 

Mortality  and  causes  of  death  after  amputa- 
tions, 610 

from  artificial  anaesthesia,  422 

from  chloroform,  422,  433 

from  ether,  423 

from  nitrous  oxide,  423 
Mortification,  amputation  for,  562 
Motion,  passive  and  active,  526 
Mouth  in  scurvy,  291 
Movements  in  surgical  diagnosis,  346 
Moxa,  503 

Mucous  surfaces,  formation  of  pus  on,  119 
Muller's  experiments  on  shock,  367 
Muscle-beating,  526 
Muscles,  retraction  of,  in  stumps,  602 

spasm  of,  in  stumps,  602 
Muscular  movements,  effects  of  anaesthetics  on, 
407 


NECESSITY,  operations  of,  439 
Necrosis,  connective  tissue,  with  purulent 


infiltration,  12T 


712 


INDEX. 


Necrosis — 

in  stumps,  605 
Needles,  578 
Nephrism,  327 
Nerves,  delirium  from  lesion  of,  383 

vaso-motor,  11 
Nervous  centres,  toxic  effect  of  anaesthetics  on, 
414 
supply,  defective  or  deranged,  causing  in- 
flammation, 71 
system,  central,  white  and  gray  matter  of, 
47 
influence  of,  on  operations,  459 
in  scurvy,  291 
in  surgical  diagnosis,  350 
Neuromata  in  stumps,  604 
New  formations,  non-inflammatory,  60 
Nitrate  of  silver  in  erysipelas,  195 
Nitric  ether,  431 
Nitrite  of  amyl,  429 
Nitrogen,  432 
Nitrous  oxide,  432 

history  of;  404 
mortality  from,  423 
Non-infective  fever,  105 

inflammation,  105 
Non-inflammatory  new  formations,  GO 
Nursing  in  inflammation,  154,  155 
Nutrition,  disturbances  of,  1 
paths  for,  33 


OAKUM,  480 
Obesity,  influence  of,  on  operations,  457 
Obstetrics,  anaesthesia  in,  416 
Occlusion,  pneumatic,  595 
Occupation  in  surgical  diagnosis,  340 
Octane,  425 
CEdema,  107 

in  scurvy,  297 

spaces  for,  33 
OEdematous  erysipelas,  183 
Oiled  silk,  482 
Old  age,  operations  in,  335 
Oilier  on  skin-grafting,  544 
Open  method  of  dressing  stumps,  597 
Operation  or  Operations,  438 

after-dressing  of,  451 

anaesthesia  in,  441 

assistants  during,  449 

care  of  bladder  after,  454 
of  bowels  after.  454 

causes  of  death  after,  472 

choice  of,  310 

condition  of  part  influencing,  470 
patient  after,  470 
before,  457 


Operation — 

conditions   determining   results   of,   456 
el  seq. 

diet  after,  453 

drainage  after,  451 

hemorrhage  in,  469,  472 

hemorrhagic  diathesis  in,  470 

hygienic  surroundings  after,  454 

immediate  dangers  of,  449 

in  infancy,  334 

instruments  for,  450 

mode  of  conducting,  448 

of  necessity  and  expediency,  439 

obesity  in,  457 

in  old  age,  335 

posture  of  patient  for,  449 

preliminary  treatment  before,  441 

preparation  for,  438 
of  patient  for,  440 

rest  before,  440 

rules  for,  during  pregnancy,  334 

shock  in,  469,  473 

time  of,  310,  439 

treatment  of  patient  after,  452 

use  of  blunt  knives  in,  451 
Operative  methods  in  amputation,  579 

surgery  in  general,  435 
Ophthalmic  symptoms  in  scurvy,  300 
Opium  in  shock,  372 
Osseous  changes  in  rachitis,  258 
Osteitis  in  stumps,  604 
Osteomyelitis  in  stumps,  604 
Oval  amputation,  584 


PAIN,  a  cause  of  shock,  359 
in  inflammation,  98 

significance  of,  in  surgical  diagnosis,  351 
Pancreas  in  scurvy,  292 
Paper-lint,  480 
Paquelin's  cautery,  505 
Paraffin  bandage,  500 
Paralysis,  hyperaemia  of,  18 
Parasites  causing  inflammation,  85 
Passive  motion,  526 
Pathology  of  inflammation,  1 
Pellets  and  bullets,  481 
Pelvis,  changes  in  bones  of,  in  rachitis,  267 
Peivtane,  425 

Perchloride-of-iron  dressing  for  stumps,  597 
Percussion,  526 
Periosteum  in  scurvy,  291 
Periostitis  in  stumps,  604 
Peritonitis,  erysipelatous,  187 
Personal  history  in  surgical  diagnosis,  341 
Petrissage,  525 
Phlebitis,  delirium  from,  393 


INDEX. 


713 


Phlegmonous  erysipelas,  182 
Phosphaturia,  331 
Physiology  of  anaesthesia,  409 
Pirogoff's  amputation,  658 
Plants,  poisonous  action  of,  causing  inflamma- 
tion, 82 
Plastic  lymph,  110 

exudation  of,  108 
operations,  classification  of,  536 
general  principles  of,  535 
rules  for,  537 
surgery,  531 

history  of,  532 
lesions  remediable  by,  533 
Pledget,  4S1 

Plethora  in  operations,  458 
Pliers,  cutting,  573 
Pneumatic  aspiration,  595 

occlusion,  595 
Pollock  on  skin-grafting,  544 
Polyuria,  331 

Poncet  on  skin-grafting,  543 
Position  in  inflammation,  144 
Posture  or  attitude  in  surgical  diagnosis,  343 

of  patient  for  operations,  449 
Pregnancy,  332 

operations  in,  334 
Prevention  of  inflammation,  138,  140 

of  shock,  371 
Prolonged  suppuration,  213 
Prostration  with  excitement,  363 
Protective,  482 
Prothetic  apparatus  for  lower  extremity,  608 

for  upper  extremity,  607 
Puncturation,  505 
Punctures  in  erysipelas,  195 
Purgatives  in  erysipelas,  197 
Purulent   infiltration  with   connective   tissue 

necrosis,  127 
Pus  absorption,  theory  of,  in  pyaemia,  204 
anatomical  characteristics  of,  116 
formation  of,  112 

phenomena  attending,  119 
on  serous  and  mucous  surfaces,  119 
liquid  portion  of,  116 
physical  qualities  of,  114 
poisonous  qualities  of,  123 
significance  of  odors  from,  122 
sources  of,  116 
substances  mistaken  for,  126 
uses  of,  124 
varieties  of,  125 
waste  of  tissue  from,  124 
Pustule,  malignant,  228,  229 
Putrid  substances  causing  inflammation,  90 
Pyaemia,  106 

and  allied  conditions,  203 


Pyaemia — 

in  amputation,  624 

chemical  theory  of,  204 

delirium  from,  393 

examination    of   blood    and    tissues    in, 
205 

experiments  on  animals  in,  206 

germ  theory  of,  205 

mechanical    and    infectious     emboli    in, 
211 

nature  of,  204 

nomenclature  of,  203 

after  operations,  477 

spontaneous,  214 

symptoms  and  lesions  of,  207 

theory  of  pus  absortion  in,  204 

treatment  of,  211 
Pyrrol,  429 


Q 


UININE  in  erysipelas,  198 
in  inflammation,  156 


RABIES,  215 
in  dog,  216 
Race,  influence  of,  on  operations,  4J1 
Rachitis,  251 

age  of  occurrence  of,  252 
anatomical  characters  of,  257 
artificial  production  of,  255 
cartilaginous  changes  in,  257 
causes  of,  254 

changes  in  bones  of  lower  extremity  in, 
267 
of  pelvis  in,  267 
of  upper  extremity  in,  266 
in  cranial  bones  in,  260 
in  maxillae  in,  264 
in  ribs  in,  265 
in  soft  parts  in,  269 
in  vertebrae  in,  264 
complications  of,  271 
connection  of,  with  laryngismus  stridulus, 

263 
craniotabes  in,  261 
deformity  in,  stage  of,  260 
diagnosis  of,  272 
diet  in,  274 

effect  of,  on  dentition,  268 
foetal,  253 
frequency  of,  251 
Heitzmann's  observations  on,  256 
from  improper  food,  254 
inheritance  in,  254 
medicines  in,  275 
osseous  changes  in,  258 


714 


INDEX. 


Rachitis — 

pathology  of,  259 

prognosis  of,  273 

proliferation  and  altered  nutrition  in,  stage 
of,  257 

reconstruction  in,  stage  of,  270 

sequelae  of,  271 

symptoms  of,  270 

treatment  of,  274 
Ravaton's  method  of  amputating,  585 
Reaction  from  shock,  369 
Redness  in  inflammation,  96 
Reflex  action,  effect  of  anaesthetics  on,  408 
Regeneration,  59 
Resolution,  136 

Respiration,  artificial,  514  et  seq. 
in  shock,  372 

effect  of  anaesthetics  on,  408 

rapid,  as  an  anaesthetic,  419 

in  surgical  diagnosis,  349 
Rest  before  operations,  440 

in  inflammation,  142 
Retractors,  481,  577 
Revaccination,  517 
Reverdin  on  skin-grafting,  539 
Revulsion,  500 

in  inflammation,  153 
Rheumatism,  311 
Ribs,  changes  in,  in  rachitis,  265 
Richardson's  bellows,  515 
Rickets,  251.     See  Rachitis. 
Roller  bandages,  483 
Roussel's  method  of  transfusion,  511 
Roux's  amputation,  658 
Rubefacients,  501 


SALTS,  ethereal,  431 
Saphena,  internal,  bleeding  from,  509 
Saturnism,  324 
Saws,  amputating,  571 
Scab,  healing  under,  111 
Scalds,  delirium  from,  389 
Scarification,  505 
Scissors,  579 

Scoutetten's  method  of  amputating,  584 
Scrofula,  240,  315 

cast's  illustrative  of,  240 

causes  and  course  of,  246 

diagnosis  of,  242 

in  gonorrhoea  and  epididymitis,  245 

in  gout,  246 

modifications   produced    in   Other  diseases 
by,  245 

morbid  anatomy  of,  242 

ual  ure  of,  241 

prognosis  of,  240 


Scrofula — 

relation  of,  to  tubercle,  244 

in  syphilis,  245 

tissues  and  organs  affected  by,  243 

treatment  of,  247 

constitutional,  247 

local,  248 
Scrofulous,  inflammation  in  the,  133 
Scultetus,  bandage  of,  497 
Scurvy,  277,  317 

cerebral  symptoms  in,  299 
from  defects  in  food,  289 
diagnosis  of,  301 
effect  of  age  in,  285 

of  depressing  emotions  in,  286 

of  food  supply  in,  28S 

of  foul  air  in,  287 

of  impure  water  in,  287 

of  individual  peculiarities  in,  287 

of  low  temperature  in,  286 

of  sex  in,  285 
embolism,  etc.,  in,  299 
etiology  of,  285 

extravasations  of  blood  and  oedema  in,  297 
fever  in,  300 

geographical  limitations  of,  285 
heart  in,  291 
hemorrhages  in,  298 
history  of,  277 

impairment  of  mental  powers  in,  296 
joints  in,  291 
kidneys  in,  292,  299 
liver,  spleen,  and  pancreas  in,  292,  300 
lungs  in,  292 
morbid  anatomy  of,  290 
mouth,  gums,  etc.,  in,  291,  296 
nervous  system  in,  291 
ophthalmic  and  aural  symptoms  in,  300 
pains  in  limbs  in,  296 
pathology  of,  293 
periosteum  in,  291 
prognosis  of,  301 
prophylaxis  of,  302 
rigor  mortis  in,  290 
scorbutic  cachexia  in,  295 
serous  effusions  in,  298 

membranes  in,  291 
skin  and  connective  tissue  in,  290 
stomach  and  bowels  in,  292 
symptoms  of,  295 
synonyms  of,  277 
treatment  of,  302 

curative,  304 
urinary  symptoms  in,  299 
from  use  of  salted  meats,  288 
Seasons,  influence  of,  on  operations,  461 
Secondary  adhesion,  union  by,  114 


INDEX. 


715 


Secretions,  effect  of  anaesthetics  on,  408 

poisonous,  of  animals,  causing  inflamma- 
tion, 82 
Sedillot's  amputation  of  leg,  661 

method  of  amputating,  586 
Sensibility,  general,  effect  of  anaesthetics  on, 

406 
Septicaemia,  106 

after  operations,  477 
Serous  effusions  in  scurvy,  298 

membranes  in  scurvy,  291 

surfaces,  formation  of  pus  on,  119 
Serpent-bites,  delirium  from,  384 
Serpents,  venom  of,  causing  inflammation,  84 
Se-ton,  503 

Sewer-gas  causing  erysipelas,  164 
Sex,  effect  of,  in  amputation,  622 
in  anaesthesia,  414 
in  shock,  359 

influence  of,  on  operations,  460 

in  surgical  diagnosis,  339 
Sheppard,  table  of  hip-joint  amputations,  678 
Shock,  357 

ammonia  in,  373 

anaesthetics  in,  374 

artificial  respiration  in,  372 

cases  attended  by,  359 

causes  of,  357 

delirium  from,  382 

external  heat  in,  371 

Goltz's  experiments  on,  366 

Lewisson's  experiments  on,  369 

from  mental  emotion,  358 

preoccupation  and  expectation,  359 

in  operations,  469,  473 

opium  in,  372 

from  pain,  359 

pathology  of,  365 

prevention  of,  371 

prognosis  of,  369 

reaction  from,  369 

stimulants  in,  372 

strychnia,   belladonna,   and   digitalis  in, 
373 

symptoms  of,  362 

Tappeiner's  and  Muller's  experiments  on, 
367 

transfusion  in,  372 

treatment  of,  371 

venesection  in,  373 
Shoulder,  amputation  above,  647 

at,  643 
Silicate-of-potassium  bandage,  50O 
Simple  dressing  of  stumps,  599 
Simultaneous  amputations,  590,  592 
Skin-grafting,  538  et  seq. 

in  scurvy,  290 


Sloughing  after  operations.  476 

of  stumps,  602 
Smell  in  surgical  diagnosis,  347 
Smith,  rachitis  or  rickets,  251 
Social  condition  in  surgical  diagnosis,  342 
Sound  in  surgical  diagnosis,  346 
Special  amputations  of  lower  extremity,  649 
et  seq. 
of  upper  extremity,  631  et  seq. 
Sphygmograph,  use  of,  529 
Spica  bandages,  488 
Spinal  cord,  suppuration  of,  48 

disease,  effect  of,  in  anaesthesia,  414 
Spiral  bandages,  485 
Spleen  in  scurvy,  292,  300 
Spontaneous  pyaemia,  214 
Starch  bandage,  500 
Stille,  erysipelas,  161 
Stimulants  in  erysipelas,  194 
alcoholic,  198 

in  inflammation,  155 

in  shock,  372 
Stokes's  amputation,  666 
Stomach  in  scurvy,  292 
Stricker,  pathology  of  inflammation,  1 
Stroking,  525 
Strychnia  in  shock,  373 
Stumps,  adventitious  bursae  in,  606 

after-treatment  of,  600 

aneurism  of,  604 

bandage  for,  495 

caries  in,  605 

contraction  of  tendons  in,  603 

diseases  of,  601 

dressing  of,  593  et  seq. 

erysipelas  and  diffuse  cellulitis  of,  602 

hemorrhage  from,  603 

hospital  gangrene  in,  602 

hypertrophy  of  bone  in,  606 

necrosis  in,  605 

neuromata  of,  604 

periostitis,  osteitis  and  osteo-myelitis  in, 
604 

retraction  of  muscles  in,  602 

sloughing  of,  602 

spasm  of  muscles  in,  602 

structure  of,  601 
Subastragaloid  amputation,  654 
Substances,  inorganic,  as  anaesthetics,  432 
Suppuration,  112 

injurious  consequences  of,  126 

prolonged,  213 

significance  of,  122 

of  spinal  cord,  48 
Suppurative  inflammation  in  connective  sub- 
stances, 37 

keratitis,  28 


716 


INDEX. 


Surface  thermometer,  528 
Surgeuu,  demeanor  of,  437 

qualifications  of,  435 
personal,  435 
Surgery,  anaesthesia  in,  416 

diagnostic  power  in,  438 

knowledge  of  anatomy  in,  436 

minor,  479 

plastic,  531.     See  Plastic  Surgery. 

operative,  435.     See  Operation. 

selection  of  cases  in,  437 

use  of  thermometer  in,  527  et  seq. 
Surgical   diagnosis,   principles  of,   337.      See 
Diagnosis. 

dressings,  479 

fever,  455 

operations,  delirium  from,  385 

or  traumatic  fever,  delirium  from,  385 

uses  of  electricity,  521 
Sutures  in  amputation,  577 
Swelling  in  inflammation,  97 
Sylvester's   method   of    artificial   respiration, 

515 
Syme's  amputation,  656 
Synchronous  amputations,  590,  592 
Syncope  during  anaesthesia,  412 
Syphilis,  319 

scrofula  in,  245 
Syphilitic,  inflammation  in  the,  134 


TAPPEINER'S  experiments  on  shock,  367 
Tapotement,  526 
Tarsus,  amputations  through,  653 
Teale's  method  of  amputating,  587 
Temperament,  effect  of,  in  anaesthesia,  414 

influence  of,  on  operations,  461 
Temperature,  effect  of  anaesthesia  on,  408 

in  erysipelas,  179 

in  surgical  diagnosis,  345 
Tenacula,  574 

Tnnlon,  suppurative  inflammation  in,  37 
Tendons,  contraction  of,  in  stumps,  603 
Tent,  481 
Tetanus,  amputation  for,  564 

delirium  from,  385 

after  operations,  476 
Tetrane,  424 

Thermometer  in  surgery,  527  et  seq. 
Thermometry  in  surgical  diagnosis,  348 
Thigh,  amputation  of,  667  et  seq. 
Thoracic  disease,  effect  of,  in  anaesthesia,  414 
Thrombosis,  delirium  from,  382 

after  operations,  475 
Thumb,  amputation  of,  634 
Tissue,  apparent  migration  of  cells  in  midst 
of,  34 


Tissue — 

inflammatory  changes  of,  24 

metamorphosis,  doctrine  of,  27 

production,  136 
Tissues,  degeneration  of,  61 

examination  of,  in  pyaemia,  205 
Toes,  amputations  of,  649 
Touch  in  surgical  diagnosis,  345 
Tourniquet  in  amputation,  565 

invention  of,  555 
Tow,  479 
Toxic  effect  of  anaesthetics  on  nervous  centres, 

414 
Transfusion,  arterial,  513 

of  hlood,  509  et  seq. 

indirect,  511 

in  shock,  372 
Translucency  in  surgical  diagnosis,  345 
Transplantation  of  cutis,  58.     See  Skin-graft- 
ing. 
Traumatic  delirium,  379 
diagnosis  of,  393 
treatment  of,  394 

fever,  99,  455 
Trichlorethane,  428 
Tripier's  amputation,  655 
Trousseau,  treatment  of  erysipelas,  192 
Tuhercle,  231 

analysis  of  cases  of,  234 

cases  illustrative  of,  231 

infection  of,  236 

morbid  anatomy  of,  234 

nature  of,  237 

origin  and  natural  history  of,  235 

pathology  of,  238 

treatment  of,  238 
Tuberculosis,  316 
Turpentine,  425 

ULCERATION,  120 
Union  by  first  intention,  111 
by  secondary  adhesion,  114 
Upper  extremity,  amputations  of,  631 
Urinary  organs,  influence  of,  on  operations,  4G5 
symptoms  in  scurvy,  299 

VACCINATION,  516 
Van  Bcren,  inflammation,  65 
Vnso-motor  nerves,  1 1 
Velpeau's  bandage,  493 
Venesection,  508 

in  shock,  373 
Veins,  air  in,  after  operations,  476 
Vermale's  method  of  amputating,  585 
Verneuil,  reciprocal  effects  of  constitutional 
conditions  and  injuries,  307 


INDEX. 


717 


Vertebra,  changes  in,  in  rachitis,  264 
Vesicants,  501 

Virchow's  theory  of  inflammation,  25 
Visceral  affections,  influence  of,  on  operations, 

463 
Vital  processes  in  basis  substance,  34 
Volition,  effect  of  anaesthetics  on,  407 


WADDING  dressing  of  stumps,  598 
Wales,  scurvy,  277 


Wandering  erysipelas,  178 
Water  dressing  of  stumps,  5!>3 

proof  paper,  482 
Waxed  paper,  482 

Weather,  influence  of,  on  operations,  401 
Weight  in  surgical  diagnosis,  345 
Wet  or  bloody  cupping,  506 
Wood  spirit,  430 
Wounds  causing  inflammation,  75,  70 

lacerated,  delirium  from,  387 
Wrist,  amputation  at,  0'37 


END  OF  VOL.  I. 


